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Limb Salvage in Children

Mikel San-Julian, B. L. Vazquez-Garca, and L. Sierrasesumaga

Contents Abstract
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4252 In recent years, the treatment for children
with bone tumours has advanced. These
Aetiology and Classification . . . . . . . . . . . . . . . . . . . . . . 4252
advances are largely due to chemotherapeutic
Anatomy, Pathology and Physiology . . . . . . . . . . . . 4255 developments, although the basis of good
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4255 treatment remains highly specialized, experi-
Clinical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4255 enced and multi-disciplinary teamwork. The
Imaging Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4255 corresponding increase in survival combined
Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4256
with the demanding functional requirements
Non-Surgical Treatment of Bone Tumours . . . . . 4257 of these young patients challenge the surgeon
Ewings Sarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4257
with limb salvage and reconstruction proce-
Osteosarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4257
dures. Surgery is carried out in two steps.
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 4258 Firstly, en bloc resection and secondly recon-
Pre-Operative Preparation and Planning . . . . . . 4258 struction. The range of possibilities involving
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4259 the available biological and non-biological
Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4260 materials is broad. The success of such surgery
Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4262 in conserving a limb hinges on thoughtful and
Post-Operative Care and Rehabilitation . . . . . . . . 4271 creative pre-operative design and planning.
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4273
Peri-Operative Complications . . . . . . . . . . . . . . . . . . . . . 4273 Keywords
Post-Operative Complications . . . . . . . . . . . . . . . . . . . . . 4275 Aetiology and classification  Chemotherapy 
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4278 Children  Complications  Diagnosis 
Ewings sarcoma  Limb salvage  Non-
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4278
surgical treatment  Osteosarcoma  Recon-
struction-allografts, extending prosthesis,
bone lengthening  Resection, growth-plate
preservation, joint preservation, physeal dis-
traction, intra-epiphyseal osteotomy  Reha-
bilitation  Surgical indications  Surgical
M. San-Julian (*)
Techniques
Department of Orthopaedic Surgery, University of
Navarra, Pamplona, Spain
e-mail: msjulian@unav.es
B.L. Vazquez-Garca  L. Sierrasesumaga
University of Navarra, Pamplona, Spain

G. Bentley (ed.), European Surgical Orthopaedics and Traumatology, 4251


DOI 10.1007/978-3-642-34746-7_179, # EFORT 2014
4252 M. San-Julian et al.

Conservative surgery in children is a chal-


Introduction lenge for the Orthopaedic surgeon because of
the small size of the patients and, the possibility
Bone sarcomas are rare [112]. The treatment of of secondary limb-length discrepancies and
bone tumours in children requires a multidis- functional requirements. The increase in survival
ciplinary approach combining surgery, chemother- thanks to chemotherapy makes this challenge all
apy and radiotherapy and based on early diagnosis the more important.
and on the experience of the whole medical There are various types of limb salvage
team. It is for this reason that these patients should procedures: biological (allograft and autograft),
be treated in specialized centres (Fig. 1). non-biological (megaprosthesis, expandable
Since the early 1980s, it has been well known prosthesis) and combined (allograft-prosthesis).
that conservative limb surgery for bone sarcomas In this chapter, we will discuss and
does not reduce the possibilities of survival. describe the different techniques of limb salvage
Thus, in most centres with experience, conserva- in children.
tive limb surgery is the usual treatment option.
This approach, however, is much more disputed
in the case of children. The possibilities for Aetiology and Classification
reconstruction are reduced (results with prosthe-
ses in children are not as good as they are in Primary malignant bone tumours are more
adults, prostheses have to be custom made, etc.) frequent in children than adults, although they
and there is an obstacle to reconstruction in only represent 5 % of all paediatric malignancy
children which does not exist in adults: possible [10, 13, 14].
limb length discrepancies secondary to resection The most frequent bone sarcomas are osteosar-
of growth cartilage. coma (two cases per million per year) and Ewings
The possibility that a child might require sarcoma (0.5 cases per million per year). Other
several operations throughout the growth period tumours are rarities. Ewings sarcoma is more
has prompted some authors to advise amputation frequent at earlier ages, whilst osteosarcoma inci-
as the first option in these cases. There are, dence peaks in adolescence.
however, alternatives to amputation that, besides In some sarcomas, such as Ewings
similar results in terms of survival, give much sarcoma, the genetic alteration responsible for
better functional results. uncontrolled cellular multiplication is known.
Functional results are only important if the To be precise, for Ewings sarcoma the alteration
patient survives. The prognosis depends both on is a translocation between chromosomes
good surgery and on a good response to chemo- 11 and 22. In osteosarcoma, however, the damage
therapy. With current protocols, survival rates of is multifactorial: various genetic pathways are
about 70 % are achieved with paediatric bone altered.
sarcoma patients. The physical or chemical causes that provoke
The objective of surgical treatment is to these genetic alterations have not been found. It
remove the whole lesion en bloc, conserving as is known that radiation of some pre-existing
much function as possible. In the past, imaging benign lesions can induce an osteosarcoma,
techniques did not allow surgeons to plan resec- but this is not a cause of the disease in children
tions with certainty, and so, to be sure that wider but rather in adults. In some cases there
resection was not necessary, a surgeon would is a family or personal history of retinoblastoma,
have to wait for the results of histological exam- other patients exhibit the Li-Fraumeni
ination of the resected material before commenc- syndrome.
ing with reconstruction. Nowadays, with modern All Ewings sarcomas are high-grade in terms
imaging techniques such as MR, this is not of malignancy. In 10 % of cases the tumour is
usually necessary. extra-skeletal.
Limb Salvage in Children 4253

A small percentage of osteosarcomas are central Currently, most research into sarcomas
or superficial tumours of low grade (low-grade focusses on the altered genetic pathways,
central osteosarcoma, parosteal osteosarcoma, the main objectives being to identify prognostic
periosteal osteosarcoma). However, most osteosar- factors and to find the causes for resistance
comas are high-grade and intramedullary; they are to chemotherapy. We trust these studies will,
classified by their predominant histological in the future, find new therapies that are
subtype (osteoblastic, chondroblastic, fibroblastic, more effective in the treatment of sarcomas:
and telangiectatic). There also exists an extra- despite great advances, 30 % of affected children
skeletal osteosarcoma, but this is a rarity. still do not survive the disease.

Fig. 1 (continued)
4254 M. San-Julian et al.

Fig. 1 (a) Ewings sarcoma in a 9-month-old baby. The from the growth-plate. (c) The tumour was resected en-
tumour is in contact with the most important growth-plate bloc and reconstruction was carried out with grafts of
of the skeleton. (b) Consecutive X-ray sequence of autologous bone from the ipsilateral fibula and tibia. (d)
response to neo-adjuvant chemotherapy. The tumour Incorporation of the graft was excellent, as was function.
became progressively smaller, moving away from the Six years later, the patient remains free of disease. No
physis. The cortex enlarged, and healthy new bone arose further limb length discrepancy was observed
Limb Salvage in Children 4255

Swelling. These tumours usually grow at great


Anatomy, Pathology and Physiology speed.
Pathological fractures. It is not infrequent that
Most malignant tumours are located in the a bone tumour first makes its presence known
metaphysis close to the growth-plate. Functional with a pathological fracture. Such fractures
results are better if tumour resection conserves appear in 28 % of benign tumours and 18 %
nearby joints. Growth cartilage represents of malignant ones.
a temporary barrier to the tumour, but involve- Laboratory data. Alterations in these data are
ment of the epiphysis is only a matter of time, and not usually specific. ESR can be elevated in
therefore early diagnosis helps in conservation of Ewings sarcoma cases. Elevated alkaline
an adjacent joint. The growth-plate possesses phosphatase indicates osteoblastic activity,
special morphological characteristics worthy of for example, in osteosarcoma. However,
mention. It is sufficiently elastic to allow intersti- normal levels of alkaline phosphatase do not
tial growth but sufficiently rigid to support the exclude the possibility of a malignant
skeleton. Vascularization of the cartilage is poor, neoplasm. Levels of calcium and phosphorus
and there are no vessels that cross from the ions are not altered initially, but, in lytic met-
metaphysis to the epiphysis [15]. Figure 2 is astatic tumours, there is an increase in
a schematic representation of the growth-plate. hydroxyproline and calcium in the urine.
Osteosarcoma usually occurs within the Location. It is unusual to encounter malignant
metaphysis of the long bones. The most common bone tumours in the hands or feet. Tumour in
location, 70 % of cases, is around the knee. the trunk or pelvis, however, are more likely to
Ewings sarcoma is more frequent in axial be malignant. In most cases, there is a single
locations, such as the pelvis, spinal column, scap- location. Most osteosarcomas occur near the
ula, clavicle and ribs, but is occasionally found in knee. Ewings sarcomas tend to occur in axial
other locations, such as the foot. When a Ewings locations.
sarcoma appears in a long bone, it usually does so In summary, the signs of malignancy are intense,
in the diaphysis. permanent and increasing pain (that does not
cease at night, with rest or with analgesics)
and rapid tumour growth associated with heat
Diagnosis and a local venous network.

The diagnosis of bone tumours is based on three Imaging Methods


pillars that must be in complete agreement
[3, 8, 1620]. The first pillar is the patients Plain X-ray. This is a highly valuable method
clinical history. The second is imaging. And the when confronted with the suspicion of a bone
third is an anatomical-pathological study. None tumour: it provides information about location
of these three must be interpreted in isolation. and morphology of a lesion. In addition, X-ray
imaging allows us to study the morphology
(lytic, blastic, expansile or not), the outline
Clinical History (with well-defined borders, sclerotic or dif-
fuse) and whether the cortex is affected or
Age. Ewings sarcoma is more frequent in not (destruction or fracture). The diagnosis of
infancy whilst osteosarcoma is more frequent a bone lesion should not be made without
in adolescence. a plain X-ray.
Pain. It is frequently the case that malignant Chest X-ray and CT scan. These images must
tumours produce pain that is constant, even at be obtained before commencing with any
night, and does not cease either with rest or treatment because these tumours metastasize
with common analgesics. hematogenously to the lung.
4256 M. San-Julian et al.

Fig. 2 The layers of the


growth-plate are
schematically represented
here. The growth-plate can
be a barrier to tumour Metaphysis
spread in some cases. When Degenerative and
an epiphysiolysis is Calcification Zone
performed, the physis is
broken through the
degenerative-calcification
zone, on the metaphyseal Hypertrophic Zone
side

Proliferative Zone

Reserve Cells Zone

Epiphysis

CT. This is a useful method for seeing Bone Scintigraphy. This is used to rule out
fractures and diagnosing tumours in areas of multifocal lesions, skip metastasis etc.
complex anatomy, such as the scapula, pelvis Angiography. This technique provides infor-
and sacrum. Contrast is used for studies mation useful in the evaluation of the vascu-
involving large neurovascular structures or larization of a neoplasm, which is important
highly vascularized lesions. when planning surgery. In some cases, angi-
Magnetic resonance imaging. MRI is ography is used as a therapeutic procedure: to
a fundamental tool in the study of the intra- administer intra-arterial chemotherapy or to
and extra- osseous extension of tumours, in perform an embolization of hypervascularized
determination of the involvement of soft tis- zones.
sues and neurovascular structures, and in the In summary, diagnosis is made on the basis of
evaluation of peritumoural oedema. It is not as basic X-ray techniques; tumour extension is
satisfactory as CT for evaluating destruction determined by magnetic resonance.
of the cortex, microfractures and calcification
in the tumour matrix. T1-weighted sequences
increase the contrast between tumour and Pathology
bone, bone marrow and adipose tissue. T2-
weighted sequences increase the contrast The biopsy of an osseous lesion can have signifi-
between tumour and muscle; in addition, T2 cant prognostic and therapeutic consequences.
sequences accentuate peritumoural oedema. A badly-done biopsy can seriously jeopardize the
Gadolinium contrast is useful to study vascu- possibilities of conservation of the affected limb or
larization of a tumour and to evaluate even compromise the prognosis. Therefore, biopsy
response. should be done by the team that is going to carry
Limb Salvage in Children 4257

out the definitive treatment of the patient. Recent Although retrospective series from individual
research at various centres has shown that institutions indicate that local control and
a quarter of surgical biopsies of musculoskeletal survival are better with surgery rather than
neoplasms are carried out in an inappropriate way with radiotherapy, the majority of these studies
[15, 16, 18], incorrectly interpreted or both. are compromised by a bias in the selection of
For an experienced pathologist practiced in patients. For patients subjected to macroscopic
this area, a needle biopsy or Tru-cut biopsy will resection but with residual microscopic disease,
be sufficient. Open biopsy can be indicated when the value of adjuvant radiotherapy is disputed
the sample obtained by needle is not representa- [23]. It is not known whether higher
tive enough. Immunohistochemistry can be doses of radiotherapy might improve results. In
a useful complement to conventional histology. general, surgery is used as the definitive
With some tumours, such as Ewings sarcoma, in local treatment when a patient is suitable;
which an 1122 chromosomal translocation is radiotherapy is reserved for patients with
characteristic, diagnosis can be established easily unresectable disease or for whom surgery would
by means of PCR techniques. Searching for DNA suppose serious morbidity. Adjuvant radiot-
transcripts in peripheral blood can be useful in the herapy must be considered for patients with resid-
follow-up of patients. ual microscopic disease and/or inadequate
surgical margins that leave residual disease in
the tumour bed.

Non-Surgical Treatment of Bone


Tumours Osteosarcoma

Ewings Sarcoma Effective treatment of osteosarcoma (OS)


requires the combination of systemic chemother-
In general, patients receive pre-operative apy and complete resection of all clinically
chemotherapy before local control measures are detectable disease. In randomized clinical stud-
instituted. For patients who undergo surgery, the ies, both adjuvant and neo-adjuvant chemother-
planning of post-operative therapy takes apy have been observed to be effective in
into account the surgical margins and his- preventing recurrence in patients clinically
tological response. In the EUROEWING- defined as free of non-metastatic tumours [24].
INTERGROUP-EE99 study [21], to determine Almost all patients are given pre-operative
subsequent radiotherapy, patients receiving only intravenous chemotherapy as an initial treatment.
radiation for local control were stratified on the Current chemotherapy protocols include combi-
basis of the pre-treatment volume of the tumour. nations of high-dose methotrexate, doxorubicin,
Most patients with metastatic disease have a good cyclophosphamide, cisplatin, ifosfamide,
initial response to pre-operative chemotherapy; etoposide and carboplatin [25]. Although most
however, in the majority of these cases, the patients with osteosarcoma receive high-dose
disease is only partially controlled or re-appears methotrexate as part of the initial treatment,
[22]. Adequate local control of metastasis sites, patients treated with doxorubicin, cisplatin,
particularly with bone metastasis, may be an cyclophosphamide and vincristine (without
important matter. high-dose methotrexate) have similar results to
Chemotherapy in ES is based on combinations those receiving high-dose methotrexate [26].
of vincristine, doxorubicin, ifosfamide and The majority of osteosarcoma treatment pro-
etoposide. Most protocols also use cyclophospha- tocols use an initial period of systemic chemo-
mide and dactinomycin. The duration of primary therapy before definitive resection of the primary
chemotherapy is between 6 months and approxi- tumour. The pathologist evaluates the degree of
mately a year. necrosis in the resected tumour. Patients with at
4258 M. San-Julian et al.

least 90 % necrosis of the primary tumour after receive post-operative chemotherapy with the
induction chemotherapy have a better prognosis same drugs as administered pre-operatively.
than patients presenting less necrosis [27]. These patients are randomly assigned additional
Patients with less than 90 % necrosis in the pri- treatment with the pegylated form of interferon
mary tumour after initial chemotherapy have alpha 2b. Patients with a standard histological
a higher rate of relapse in the first 2 years in response (10100 % of the tumour is viable)
comparison to patients with at least 90 % necrosis also receive post-operative chemotherapy with
[27, 28]. Imaging techniques, such as dynamic the same drugs as administered pre-operatively,
magnetic resonance imaging and positron emis- but are randomly assigned additional treatment
sion tomography (PET), are currently being with more or less cycles of ifosfamide and
investigated as possible non-invasive methods etoposide.
of evaluating response. Less necrosis must not
be interpreted as meaning that the chemotherapy
has been ineffective: cure rates for patients with Indications for Surgery
little or no necrosis after induction chemotherapy
are much higher than those rates in patients who Most patients should be considered for surgery
do not receive such chemotherapy. (even if metastases are present). The different
In some studies, the degree of tumour necrosis types of limb salvage surgery can be classified
is used to determine the post-operative chemo- by location of the tumour:
therapy. In general, if the tumour necrosis Joint resections.
exceeds 90 %, the pre-operative chemotherapy Diaphysis resections:
regime is continued. If the necrosis is less than Epiphysiolysis prior to resection.
90 %, some groups have added drugs not previ- Intra-epiphyseal or metaphyseal osteotomy.
ously used in the pre-operative treatment. This According to the implanted material, recon-
approach is based on the first reports from the structions can be:
Memorial Sloan-Kettering Cancer Center Biological: allografts or autografts.
(MMSKC) that indicated that results in patients Non-biological: megaprosthesis or expand-
with less than 90 % tumour necrosis were able prosthesis.
improved by adding cisplatin to post-operative Combinations of prosthesis and allograft.
chemotherapy. With a longer follow-up, how-
ever, the results in patients with less than 90 %
tumour necrosis and treated in the MSKCC were Pre-Operative Preparation
the same whether patients received cisplatin in and Planning
the post-operative stage of treatment or not.
Subsequent studies carried out by other groups The best moment for surgery must be agreed by
have not demonstrated an increase in survival consensus with the rest of the team treating the
when drugs not included in the pre-operative patient, so as not to interfere with the chemother-
regimen were added to the post-operative apy protocol. In general, patients receive several
treatment [27, 29]. cycles of neo-adjuvant chemotherapy before
The Childrens Oncology Group (COG), with undergoing surgery because the chemotherapy
the collaboration of several European groups, has facilitates limb-conservation surgery. Chemo-
started a study in which all patients receive a pre- therapy can delay surgery; and surgery, if
operative treatment with doxorubicin, cisplatin, complications (for example, infection) are
and high-dose methotrexate. After surgery, encountered, can delay administration of the che-
patients are divided into two groups on the basis motherapy adjuvant.
of histological degree of necrosis in the resected When designing limb salvage surgery, our
primary tumour. Patients with favourable histol- basic tool is magnetic resonance imaging. In the
ogy (less than 10 % of the tumour is viable) all first consultation, the patient has a baseline
Limb Salvage in Children 4259

Fig. 3 Growth of a tumour


can displace the vascular
bundle. MRI is a reliable
tool for imaging such
displacement. The arrows
show the vascular bundle
(femoralis superficialis).
Notice the huge collateral
vascularization. * rectus
anterioris

MR image, and before surgery a second MR in order to determine the anatomy of the
image is used to evaluate the response to neo- nerve-vessel bundle, the length of the tumour,
adjuvant chemotherapy. The information from the mass of soft tissues, etc. In addition, prepara-
the image is used to design our approach to resec- tions must be made with regard to the material to
tion. The incision must allow us to deal with the be used in reconstruction.
principle blood vessels and nerves. Current com-
puter software allows us to measure the length of
the bone that we are going to resect and also Surgical Technique
assess the degree of soft tissue involvement.
Once the size of the tumour is known, the Conservative surgery for malignant bone
approach has been planned and the anatomy of tumours has two phases: resection and
the nerve-vessel bundle determined (Fig. 3), we reconstruction.
must turn our thoughts to the material for recon- To be able to cure a malignant bone tumour, it
struction. If a bone bank is available, the most is usually necessary to resect en-bloc, with safety
appropriate bone allograft must be selected. margins, the whole diseased area together with
The bone should preferably be from a young the biopsy course [30]. If a tourniquet is used an
male, because the greater extra-medullary diam- Esmarch bandage must not be used. The
eter is useful for establishing good internal fixing. approach route should be chosen on the basis of
The bone should be of appropriate length and tumour location, possible involvement of
from the same side of the body as that which is nerve-vessel structures (usually they are found
it going to substitute. In the case of placing to be displaced but not infiltrated), the location
a megaprosthesis or expandable prosthesis, the of the biopsy taken previously, the technique
same considerations apply. Many such prostheses for reconstruction to be used, etc. The tumour
are custom made and should be ordered from the should be completely removed as a whole,
relevant company, stating size and side, during without being seen. A good safety margin
the period of neoadjuvant chemotherapy. is not a question of centimeters, but rather
In summary: surgery cannot be approached of resecting the tumour through healthy tissue:
without first having studied a current MR image it is not a question of quantity but quality.
4260 M. San-Julian et al.

Rate of local recurrence is a good indicator with Physeal distraction has been extensively used
which to evaluate the quality of resection and the for bone lengthening and for correcting
efficiency of neo-adjuvant chemotherapy treat- angular deformities. Canadell described its use
ment. The planned reconstruction must never be in facilitating the excision of malignant hone
put before quality of resection: a nice post-operative tumours of the metaphysis while preserving the
X-ray is useless if the patient does not survive epiphysis.
or suffers local recurrence of his or her illness. The indications for this technique are:
1. Location of the tumour in the metaphyseal
region.
Resection 2. The physeal cartilage must be open.
A patients age is an important consideration
En bloc resection of all tumoural tissue is here. In patients who have nearly finished
obligatory in bone sarcomas. Depending on the growing the probability of tumoural cells
size of the lesion, as measured from the having crossed the physis is higher, and it is
previous MR, greater or lesser quantity of bone, more difficult to achieve physeal distraction.
together with adjacent soft tissue, will need to 3. The tumour must not have transgressed the
be removed. physis. Pre-operatively, radiography, arteriog-
In the majority of bone sarcomas, the surgical raphy, CT and particularly MRI can be used to
margin must be wide in order to reduce the risk of demonstrate this.
local recurrence. The surgical treatment recommended for these
Bone resections can be divided into diaphy- tumours depends on the stage of invasion of the
seal resections and articular resections. epiphysis as revealed by MRI (Fig. 4).
Physeal distraction is used in tumours of the
Diaphyseal Resections distal femur, proximal tibia, distal tibia, distal
When the tumour does not affect the articular end fibula, proximal humerus and distal radius. In
of the bone, it is possible to conserve the joint. This locations such as the proximal fibula or proximal
has numerous advantages for the patient. In the femur, physeal distraction is not used.
case of pediatric patients, the advantages are even The presence of a pathological fracture
greater, because the long-term problems of pros- contra-indicates physeal distraction, because the
thetic reconstruction in children can be avoided distraction will occur through the fracture instead
and because conservation of the growth- cartilage of through the growth-plate. In such cases,
makes it possible to avoid many subsequent prob- intra-epiphyseal osteotomy could be used to
lems. Loss of the joint (as occurs, by definition, conserve the epiphysis. However, if the fracture
under any articular resection) can later lead to heals during neo-adjuvant chemotherapy
a significant degree of functional deficit. period, it is still possible to perform physeal
It was for this reason, to avoid loss of the joint, distraction.
that Professor Canadell developed, in 1984, The surgical technique usually consists of two
a technique to allow conservation of the articula- steps [15].
tion and with it conservation of a great part of
growth potential. First Step Two pins are inserted into the epiph-
ysis and another two into the diaphysis, 810 cm
Canadells Technique away from the tumour (Fig. 5). An external
Histological Fundamentals, Image Methods monolateral fixator with a T-shaped piece for
and Indications the epiphyseal pins is attached.
Traditionally, the physis has been regarded as Distraction is begun in the operating room
a barrier capable of preventing tumour extension and continues at the rate of 11.5 mm/day until
in some cases. Such extension relates to both 1 or 2 cm of distraction is achieved. During the
delay in diagnosis and tumour aggresion [15]. first few days nothing happens, but usually
Limb Salvage in Children 4261

Fig. 4 Indications and Ideal Possible


contra-indications for Indication Indication Contraindications
Canadells technique

First surgical step 10-15 days the operation is completed by reconstruction


with an intercalary graft.
The choice of the kind of osteosynthesis
device in the graft and in the remaining physis
and epiphysis can play an important role in the
final limb length discrepancy. In this respect, for
children near the end of growth it may be appro-
priate to insert an allograft longer than the
resected piece.
In all cases, histological examination of
resected pieces should be performed to confirm
that the tumour had not involved the growth-
plate.
Subsequent growth of a limb is not only
affected by the surgical technique employed in
terms of the resection of one or more growth-
plates. Even in cases where the growth-plate is
left intact, the osteosynthesis device or radiother-
apy [1618, 33] could cause arrest of growth. In
addition, high doses of chemotherapy have been
Fig. 5 Diagram showing the first surgical step
reported to result in a decrease in GH secretion.
Physeal distraction before excision can preserve
most of the growth-plate because the physis
after between 7 and 14 days of distraction breaks at the metaphyseal border of the growth-
the patient reports pain indicating rupture of the plate as a result of the degenerative lack of cells
growth-plate: radiography will show disruption there (Fig. 7).
of the physis.
Possible Complications and Their
Second Step En-bloc resection of the tumour is Solutions Although in the vast majority of
performed by diaphyseal osteotomy, leaving cases, on carrying out distraction at a rate of
a wide margin (Fig. 6). The metaphyseal end of 1 mm/day, rupture of the cartilage occurs through
the resection has already been affected by dis- the layer of degenerative cells, the possibility of
traction. If the prior imaging methods clearly rupture occurring in the wrong place does
indicated the absence of tumour in the epiphysis, exist (and occurs in about 23 % of cases).
4262 M. San-Julian et al.

Fig. 6 Diagram showing Second surgical step


the second surgical step

Tumor Graft

Retained epiphysis together with


most of the growth-plate

If this happens, it is still possible to conserve the reconstruction of both the bone and the joint more
epiphysis without increasing the likelihood of difficult.
local recurrence by carrying out an intra- An articular resection implies loss of
epiphyseal osteotomy. the growth-plate adjacent to the joint. Articular
cartilage is usually a barrier to tumour spread, and
Other Techniques for Preserving Joints so resection of the other bone of the joint is not
In selected cases, the epiphysis can be preserved necessary. If the tumour has spread through the
by intra-epiphyseal osteotomy [31] (Fig. 8). We ligaments or capsule, then an extra-articular
believe that intra-epiphyseal osteotomy is indi- resection should be performed.
cated in the following particular situations:
Metaphyseal tumours with no involvement of
the physis in which a pathological fracture has Reconstruction
occurred.
Metaphyseal tumours in contact with part of Reconstruction is not needed after resection
the growth-plate. of bone sarcomas at some locations; tumours of
Metaphyseal tumours without involvement of the patella, proximal and middle fibula, rib,
the physis, but in patients who are close to the clavicle, scapula, zone III of pelvic bone, etc. can
end of growth. be extirpated without provoking large functional
deficits (Fig. 9). In some cases reconstruction can
Articular Resections be useful for aesthetic purposes.
When a tumour involves the epiphysis,
usually the articular edge of the bone must to be Biological Reconstruction
resected. In such cases, the capsule, the extra- and For bone reconstruction we can use auto- or allo-
intra-articular ligaments, the tendinous attach- grafts. Bone grafts have the function of pro-
ments, etc. should be removed. This makes resec- moting osteogenesis and providing mechanical
tion surgery more complicated, and it also makes support.
Limb Salvage in Children 4263

Fig. 7 (continued)
4264 M. San-Julian et al.

Fig. 7 (a) Clinical aspect, X-ray and MRI of an osteo- of the extension of the tumour. (c) Intra-operative image
sarcoma involving almost the whole femur in a 12 year- of the tumour. See the accurate dissection of the vascular
old boy. (b) Epiphysiolysis was performed. In this case, bundle. (d) Resection and reconstruction with an interca-
the proximal pins were placed at the femoral neck because lary allograft (marked with arrows)
Limb Salvage in Children 4265

b c

Fig. 8 (a) Osteosarcoma of the distal femur in contact Reconstruction was carried out with an intercalary allo-
with the full physis. (b) Intra-epiphyseal osteotomy for graft. Epiphysis is free of tumour. Lines shows the
joint preservation in a case of osteosarcoma of the femur. planification of the osteotomy. (c) Functional results
4266 M. San-Julian et al.

Fig. 9 Two cases involving locations that required no reconstruction. (a) Clavicle. (b) Fibula
Limb Salvage in Children 4267

Allografts non-union and an unstable joint. In growing


There are two types of bone allograft in children, this reconstruction method can be
existence [7]: used as a temporary solution. Once the child is
Cancellous bone: generally this is near to the end of growth, the osteo-articular
obtained from live donors (from the head of allograft can be converted into a composite
the femur in hip replacement patients) allograft-prosthesis. If necessary, a lengthening
although it can also be obtained from procedure can be performed at the time of this
cadavers. This is the most frequently used second surgery.
type of graft, with multiple uses in Orthopedic
surgery. Autografts
Cortical bone: this is only obtained from Autologous bone (autograft) has been shown to
cadavers. perform better biologically than non-autologous
The use of grafts requires knowledge of con- bone. However, quantities are limited, morbidity
solidation times and of how the grafts related to the site of extraction is an important
develop radiologically. The average consolida- consideration, and there are difficulties in
tion time for a metaphyseal osteotomy is the reconstruction of large defects with this type
6.5 months. In contrast, for a diaphyseal of graft.
osteotomy, consolidation takes on average Autografts can be vascularized (that most
16 months. In cases of pseudoarthrosis, autolo- frequently used is from the fibula),
gous grafts are used in order to promote union. non-vascularized or a mixture of both. With auto-
Cortical bone allografts are associated with a grafts, consolidation is faster, integration is better,
higher rate of complications than those of cancel- but availability is lower and mechanical properties
lous bone. Stabilization of the graft must be suf- are worse: the mechanical stress is greater because
ficiently secure to allow consolidation. the diameter is smaller. For this latter reason, these
Depending on the location, there are different grafts are employed mostly in reconstructions:
techniques: Kirschner wires, osteosynthesis Of the upper extremities
plates, intramedullary nails, etc. After resection of small tumours
At the metaphyseal level, it has been demon- After failure with other reconstruction tech-
strated that consolidation takes place quite easily niques, and
whichever method is used, and so complex and For aesthetic reasons.
laborious fixation methods are not necessary; Vascularized autografts from the proximal fib-
crossed Kirschner wires are sufficient in most ula and including growth cartilage have been
cases (Fig. 10). used as the reconstruction method in the proximal
At the diaphyseal level, consolidation is slower humerus, distal radius, and proximal femur.
and more problematical. The use of an Transplanted growth cartilage can continue
intramedullary nail allows the patient to put growing and thus diminish any final dissymme-
weight on the limb earlier than when plates try. Mechanical demands of the receiving articu-
are used in the fixation method. The shape of lation can have a molding effect on the end of the
the osteotomy is not a determining factor on bone graft and even make it similar to the end of
the result. the resected bone [32] (Fig. 11).
When the joint surface needs to be resected in After resection of small tumours, a non-
children, an osteo-articular allograft can be vascularized autograft (extracted, for example,
used for reconstruction. This is a biological from the tibia, fibula, and/or iliac crest) has
solution, replacing the bone stock and allowing great advantages: it integrates more easily, and
re-attachment of ligaments, capsule, etc. once it has consolidated it can be considered as
The drawbacks with this technique include artic- a lifetime reconstruction. When the fibula is used
ular degeneration, fracture (the cortical bone at as donor bone, the most distal part should be kept
the metaphyso-epiphyseal area is quite thin), intact if possible. If not, axial deformity
4268 M. San-Julian et al.

Fig. 10 This patient with a Ewings sarcoma suffered ligaments and the patients potential for growth. The
a pathological fracture. Neo-adjuvant chemotherapy was diaphyseal osteotomy required strong osteosynthesis
very effective and the fracture healed. Epiphysiolysis was whilst the metaphyseal end healed with just two Kirschner
performed in order to preserve the joint, capsule, wires

of the ankle can occur. If a non-vascularized fractures. A small percentage of patients can suf-
graft is employed, a subperiosteal resection fer from these complications (infection or fac-
of the fibula allows for subsequent neoformation. ture) many years after implantation, something
Another possible donor bone is the tibia. that does not occur with autografts.
An anterior-internal cortical window can be
used, and with time the tibia will remodel. Combination of Allografts and Autografts
Finally, the iliac crest is the most common Capanna described a combined reconstruction
donor site. technique in which a vascularized autograft from
After resection of large diaphyseal tumours, it the fibula is embedded within a window in the
may be necessary to resort to allografts. These allograft. In this manner, the best is made of
have excellent or good functionality in 80 % of both the mechanical advantages of the allograft
cases [33] although they are associated with and the biological advantages of vascularized
higher rates of infection, pseudoarthrosis and fibula [34].
Limb Salvage in Children 4269

Fig. 11 A vascularized
fibula including the
proximal edge and its
growth- plate can be used
for reconstruction of the hip
or proximal humerus in
growing children

Non-Biological Reconstruction multiple replacements are likely to be become


The objective of prosthetic reconstruction after necessary.
sarcoma resection is to replace the resected bone
to establish an initial fixation that allows early Hemiprosthesis
weight-bearing. A wide range of cemented and In growing children, articular resection
uncemented implants of various lengths and of tumours involving the epiphysis implies the
diameters exists. loss of one growth-plate. If reconstruction is
The designs of recent prostheses also carried out with a prosthesis, the prosthetic
provide anteroposterior and mediolateral holes stem could cause growth arrest of the other bone
for re-insertion of tendons and soft tissues. forming the joint by disrupting the second
growth-plate. For this reason, some authors
Endoprostheses: Custom Made advise reconstruction with a hemiprosthesis,
Endoprosthetic Replacement until the child finishes growing, at which time
These are used in adults and in children who are the hemiprosthesis can be converted into a total
finishing growth with an anticipated limb length prosthesis.
discrepancy of less than about 2 or 3 cm [35].
The short term results are good. They permit Extending Prostheses
early mobility and early loading. Endoprostheses Expandable prostheses were designed in the
can be modular or can be made to measure during 1980s in an attempt to resolve the problem of
the period of neo-adjuvant chemotherapy. loss of growth after resection of bone sarcomas
The main disadvantages in children are the diffi- in children. The resulting prostheses incorporated
culty in adjustment to the size of the patient and systems of elongation that required repeated
the possibility of aseptic loosening in the re-operations, each time with the corresponding
long term. In children who survive cancer, risk of infection. For this reason, that is, the high
4270 M. San-Julian et al.

infection rate, surgeons in Europe stopped using


them. Currently, however, new systems of elon-
gation based on non-invasive methods such as
electromagnetism have been developed and
have generated new enthusiasm for this approach
[1, 36, 37].
An expandable prosthesis is indicated when
a large growth disparity is predicted [38]
(Fig. 12).
Elongation is done in successive stages
of between 6 and 10 mm each time. The most
limiting factor for elongation is the tension of soft
tissues.
Prostheses allow a maximum elongation of
120 mm. Once this limit has been passed it is
necessary to change the whole prosthesis.
Recovery is faster than with biological
reconstructions: rehabilitation can commence
early.
The most frequent complications related with
this reconstruction method are infection, faults in
the expansion mechanism, and aseptic loosening
and migration of the implant. Despite these com-
plications, expandable prostheses provide a good
temporary solution for reconstruction after
tumour resection in children. Fig. 12 Distal femur expandable prosthesis, 7 years
post-surgery for osteosarcoma. Note the extension of the
prosthesis (Courtesy of Seggy Abudu, Royal Orthopaedic
Combination of Prosthesis and Allograft Hospital, Birmingham, UK)
This technique tries to optimize the advantages of
prostheses with those of allografts. The goal is
good joint stability (a constrained prosthesis)
whilst enabling re-insertion of muscle and soft surgeon is to be able to provide for each patient
tissues into the allograft. whatever is best for that patient and not to settle
In order to prepare the graft, the bone for knowledge and expertise in a single area.
deficiency resulting from tumour resection is
calculated. The graft should be the same size or Reconstruction of Soft Tissues
slightly larger than the bone removed and should After bone reconstruction, a further consideration
have a good medullary canal that can be reamed is reconstruction of soft tissues. Sometimes, it is
to a diameter compatible with the connecting rod necessary to resect such a large amount of tumour
of the prosthesis to be used. The prosthesis will be that there is not enough skin or muscle left
larger than the allograft, so that it can be embed- to cover the osteosynthesis or reconstruction
ded into healthy bone. area [39].
When reaming the graft, care is needed to Covering the implant. Use of rotation or free
avoid fracturing the bone. This is especially muscle flaps is necessary. The most com-
important if the medullary cavity is small. monly used flap is a rotation flap: the internal
In summary: Tumour resection and recon- calf muscle for defects in the proximal tibia.
struction surgery is completely patient-specific: With larger defects it is necessary to resort
each case is different. The important thing for the to the placement of vascularized free flaps.
Limb Salvage in Children 4271

This increases the risk of infection, because of patients clearly prefer such an approach rather
the increase in the number of hours under than amputation (Fig. 13).
surgery. Limb salvage in foot locations can be done in
Tendon suture. It is important to return stabil- almost all patients, as it does not diminish sur-
ity to musculature as physiologically as possi- vival rates and functional outcomes are in most
ble. Reconstruction of the extensor apparatus cases excellent.
of the knee is fundamental to the provision of a
useful, functional limb and to prevent early
failure of the prosthesis. In these cases, the Post-Operative Care and
patellar tendon can be reinserted into the inter- Rehabilitation
nal calf muscle flap. If graft-bank allografts are
being used, these grafts are usually extracted The scar requires special attention. A surgical
such that a part of each tendon is left, for wound in good condition allows an early start to
example, the insertion of the gluteal tendons, chemotherapy treatment. Usually, early removal
rotator cuffs or patellar tendons. In the case of of staples can result in dehiscence, because
arm reconstruction, a tumour sometimes chemotherapy also delays scar formation. If the
involves the rotator cuff, and reconstruction wound shows any necrotic or dehiscent zones, it
requires part of the deltoid muscle. will need to be followed up more carefully, with
Capsule reconstruction. After tumour-resec- consideration of revision.
tion, osteo-articular reconstructions with pros- If the resection was very extensive, oedema of
theses present a greater risk of subluxation the limb is to be expected, and we must start to
since, the articular capsule and surrounding take anti-oedema measures because oedema
muscle are usually affected. Therefore, the delays scarring.
joint is stabilized with a Trevira tube. Drainage tubes are usually withdrawn within
4872 h.
Tumour Treatment in Special Locations Antibiotic prophylaxis is with third-
Foot generation cephalosporin. There is no universal
Malignant bone tumours located in the foot and protocol; there are guidelines advocating 3 days,
ankle are extremely rare [40]. Ewings sarcoma 3 weeks and even 3 months.
can be located in almost any bone, only 5 % of Rehabilitation should be begun in the imme-
the cases occur in the foot and ankle. Dahlin and diate post-operative period. Irrespective of the
Unni published their experience in 8,542 bone surgery, techniques should be used on the
tumours, only 105 (1.2 %) were located at the distal limbs not compromised by surgery. These tech-
lower extremity. 54 were malignant and almost niques involve active mobilization as a means to
half of them were Ewings Sarcoma [41]. ES of preserve mobility of body segments, maintain
the distal lower extremity has better prognosis good blood circulation and make provision for
than those located in other parts of the body. recovery of motor functions.
Usually, radiotherapy, surgery or both are used With regard to the affected limb, in the
for local control of the disease. Amputation has initial phases, physical measures are used to
traditionally been the most common surgical tech- maintain, as far as possible, optimum levels of
nique. It provides excellent local control, but there musculocutaneous tone and vasomotor function.
is an inevitable loss of function. Less aggressive, In conjunction with the measures described
conservative, surgery can achieve the same above, re-absorption of oedema fluid is
excellent results in terms of survival and local potentiated by gentle manual drainage manoeu-
disease control, whilst maintaining better function vres and stimulation of venous-lymphatic
of the extremity. For reconstruction, allografts or return. At the same time, these procedures
plastic devices can be used. These provide excel- improve the local blood flow so necessary to the
lent functional results in most cases, and almost all processes of scarring and the maintenance of the
4272 M. San-Julian et al.

a b

Fig. 13 (a) Ewings sarcoma in the os calcaneum. Most reconstruction. The Achilles tendon was re-attached to the
surgeons would advise amputation. (b, c) After removing gluteal tendons of the allograft. * shows the greater
the femoral head, a proximal femur allograft was used for trochanter

tone of permanent tendomyoligamentous bone appropriate tissue regeneration times for tissue dis-
structures. placements and the characteristics of the sutures
Together with drainage manoeuvres, move- used. With unstable joints, muscle groups are
ment of the joints above and below the surgically potentiated by means of techniques of directed
affected segment are to be encouraged. Such isometric contraction and electrostimulation in
movements, however, must take into account the order to maintain muscular tone.
stability of the joint that has been operated on and Other techniques, such as hydrotherapy, elec-
the osteosynthesis methodology used. trotherapy, spectrum therapy and masso-
With stable joints, treatment with gentle passive therapy serve to help recovery of both joints
unforced physiotherapy can proceed on the first and muscles in the later stages of recovery, when
day after surgery. Such exercises must respect the the surgical wound displays favourable scarring.
Limb Salvage in Children 4273

As the stability of the surgically affected Peri-Operative Complications


body segment and joint develops, techniques
of physiotherapy involving more force are used (a) Necrosis. During surgery skin is subjected
in order to increase range. These techniques, to stress, especially when the approach
with resistance, are used to progressively used is wide: removing large amounts of
improve muscle tone and strength. Similarly, muscle tissue and leaving only a thin subcu-
when stability allows, progressive weight-be- taneous layer. Sometimes it is necessary to
aring is begun in order to retrain the patients approach the tumour and the biopsy
motor patterns. tract from varying incisions. If such
incisions are close together or form acute
angles, the blood supply to the skin can
Complications be damaged, producing necrosis. This can
delay the start of chemotherapy.
Complications can be classified on the basis of (b) Seroma. A physiological effect of muscle
when they occur: resection is development of a seroma.

Fig. 14 Limb length discrepancy and infection in the allograft prosthesis was implanted. Both complications,
same patient. After removing the implant, a lengthening length discrepancy and infection were solved in a single
of soft tissues was performed and a new longer composite course of action
4274 M. San-Julian et al.

If there are no complications to the diminishes the possibilities for sufficient


seroma, the treatment is to use stockings or coverage of bone with soft tissues; fre-
compression bandages. quently, it is necessary to make use of
(c) Infection. [4245] This is a complication muscular flaps to provide the reconstructed
that can occur both in the short and the area with sufficient coverage.
long term. After completing reconstruction The bacterium most commonly isolated in
surgery, prophylactic antibiotics are cultures is Staphylococcus epidermidis.
administered. The infection rate for the Treatment. In some cases, surgical
first operation is low (about 2 %), but cleaning and antibiotics can control an infec-
the rate following re-operations conse- tion. In most cases of infection of an allograft
quent to fracture, pseudoarthrosis, aseptic or prosthesis, however, treatment requires
mobilization etc. can be up to about 10 %. the removal of the implant, removal of
Similarly, the nature of the surgery under- necrotic tissue, substitution with a spacer
taken also affects the likelihood of for at least 6 weeks, and finally replacement
infection. Wide resection of a tumour with a new graft or prosthesis (Fig. 14).

Fig. 15 (continued)
Limb Salvage in Children 4275

Fig. 15 (continued)

How to avoid infection: aseptic and anti- is sufficient. If the subluxation is recurrent,
septic measures must be painstaking (the risk it may be necessary to change the
of infection is up to 130 greater than that with prosthesis. Constrained prostheses should be
arthroscopy). All foreign material used for considered.
reconstruction (whether metallic or biologi- In the hip, large diameter heads can be
cal) must be fully covered by muscle. When used. When such measures are not sufficient,
necessary, use muscle flaps (for example, there are synthetic materials (such as
from the medial gastrocnemius muscle in a Trevira tube) that can be used to surgically
cases of tumours in the proximal tibia). create a neocapsule for the joint.
Antibiotic prophylaxis must be maintained
for sufficient time.
(d) Subluxation/Dislocation. Resection of the Post-Operative Complications
capsule increases the risk of subluxation
despite the fact that tumoural joint prostheses Limb Length Discrepancies
are usually hinged or constrained. Resection As mentioned in previous sections, bone sarco-
of bone together with soft tissues provokes mas in childhood are usually located close to the
greater instability than that encountered with growth cartilage and their resection can result, in
a standard prosthesis placed for a fracture or many cases, in alteration in growth [46]. Limb
for arthritis. length discrepancies in the upper body are less
Treatment. In some cases, reduction limiting in ordinary life and often only result in
together with subsequent immobilization an aesthetic deficiency. In the legs, however,
4276 M. San-Julian et al.

Fig. 15 (a) Limb-length discrepancy after reconstruction (b) Bone lengthening was performed. (c) At the end of
of the distal femur with non-vascularized autograft from growth, this patient still had his knee and was free of
the fibula. Notice the equinus of the left foot the discrepancy
osteosynthesis device did not allow subsequent growth.

a discrepancy greater than 34 cm may impose elongation, for example, when a graft or insert
a real physical limitation. has to be removed due to infection or fracture.
Treatment. There are many options to resolve Elongation can be through the patients healthy
this problem. The simplest treatment is to perform bone, or the reconstruction material can be
a contralateral, percutaneous epiphysiodesis. substituted for a larger version and elongation
But, with this method it is only possible to correct applied through the soft parts. Expandable pros-
a small discrepancy, depending on the age of the theses are designed to be elongated inside the
patient. Another option is to shorten the healthy patient. However, if the length discrepancy is
limb; this, too, is only for small (45 cm) very big, it can be necessary to exchange
discrepancies. the prosthesis.
If the above procedures are not sufficient, How to avoid length discrepancies: when pos-
elongation through external fixation can sible, preservation of the growth cartilage will
be undertaken (Fig. 15). Sometimes, a complica- avert the problem of later discrepancy. For
tion can be made into an opportunity for tumours located at a distance from the physis, if
Limb Salvage in Children 4277

we perform the resection by metaphyseal of the greatest handicaps of non-biological


osteotomy, the growth cartilage remains intact. reconstructions is that multiple replacements
Note that graft osteosynthesis (if this method of will be needed during the future life of the
reconstruction is used) must respect the physis if patient.
we wish growth to continue. For tumours Treatment: Replacement of the prosthesis.
that are near to or even in contact with the physis, How to avoid loosening: improvements in
eipiphysiolysis prior to resection can materials, use of a hydroxyapatite collar on the
conserve the greater part of potential for growth. bone-prosthesis interface and improvements in
Finally, if resection implies loss of the growth cementing have lengthened the life of implants.
cartilage, we can employ a reconstruction In the case of children who survive for
method with an implant somewhat longer (2 or many years, however, it is not possible to say
3 cm at the most) than the resected piece, thereby that these developments will make revision
diminishing the final discrepancy. This can procedures unnecessary.
be more useful in patients close to the end of
their growth. Graft Fracture
Fracture of a graft is influenced by the type
Aseptic Loosening of synthesis utilised. The use of osteosynthesis
The functional demands and longer life- plates makes it necessary to perforate the
expectancy of patients mean that implants need graft at various points, and these perforations
to have a long average life [1]. Currently, one weaken the graft ostensibly. Even with

a b c

Fig. 16 (a) Fibrosarcoma of the femur in a 16-year-old (c) A new osteosynthesis device and autologous bone
girl. (b) An intercalary allograft was used for reconstruc- graft supplementation were used to resolve this
tion, but the proximal osteotomy failed to unite. complication
4278 M. San-Julian et al.

endomedullary nails as the means of fixation, it is


necessary to avoid placing locking screws, which Summary
reduce the resistance of the construct [47].
Fractures in allografts start to appear 2 years In the last few years it has become clear that in
after implantation and can even appear many most paediatric cases of bone tumour it is possi-
years later. This possibility is very rare with ble to use reconstructive surgery with limb pres-
autografts. ervation and thereby improve these patients
The treatment of an allograft fracture consists function and quality of life. We should not forget
of strict immobilization of the fracture with an that this is thanks to a multidisciplinary approach,
adequate osteosynthesis device. In this way an which has improved prognosis tremendously, and
osseous callus forms, which demonstrates the via- thanks to the efforts of our predecessors and their
bility of the graft despite it being a bone containing innovation.
a large component of necrotic matter: such a graft
still has the capability of inducing the formation of
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