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Die extrakorporale Bestrahlung

Replantation von Knochensegmenten bei malignen Knochentumoren

Extracorporeal irradiation

Reimplantation of bone segments in the treatment of malignant bone tumours

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Zusammenfassung

Hintergrund

Maligne Knochentumoren und die durch sie notwendige weite Resektion führen meist zu großen Knochendefekten am betroffenen Skelettabschnitt. Autologe Knochentransplantate stellen eine bewährte Rekonstruktionsoption dar, sind jedoch hinsichtlich Länge und Durchmesser sowie der Anwendbarkeit im gelenknahen Bereich limitiert. Mit der extrakorporalen Bestrahlung (EKB) und Reimplantation des betroffenen Knochensegmentes stellen wir im Folgenden eine weitere biologische Rekonstruktionsmöglichkeit vor.

Diskussion

Es werden die Indikationen und Kontraindikationen, Details der Operationstechnik sowie das empfohlene Nachbehandlungsschema näher beleuchtet. Eigene Ergebnisse sowie Ergebnisse aus der Literatur werden eingehend vorgestellt sowie Erfahrungen, Risiken und Komplikationsmöglichkeiten der Techniken kritisch diskutiert.

Schlussfolgerung

Zusammenfassend bietet die extrakorporale Bestrahlung den Vorteil einer hohen Passgenauigkeit, einer Refixationsmöglichkeit für wichtige Weichteilstrukturen sowie einer meist guten postoperativen Funktion. Die Anwendung der Methode ist besonders bei gut erhaltenem Knochenstock im tumortragenden Segment und bei Tumorresektionen an Becken, Femur und Tibia empfohlen.

Abstract

Background

Malignant bone tumors themselves and the wide resection required because of them may cause huge bone defects in the bone segment involved. Autologous bone grafts are a reliable option to cover these defects in many cases but their availability is limited. Besides common alternative reconstruction methods, including the use of allografts and/or prostheses, especially extracoroporeal irradiation (ECI) and reimplantation of the bone segment involved is attracting increasingly more attention nowadays.

Discussion

In the following, we report on indications/contraindications, details of the operative technique, as well as the recommended rehabilitation regime of ECI. Furthermore, we compare our own results with those published in the recent literature. Especially the advantages and disadvantages of this method, the risks and the complications are illustrated and critically discussed.

Conclusion

Extracorporeal irradiation of a tumor bearing bone segment is a valuable alternative reconstruction technique following tumor resections of the pelvis, femur and tibia, with encouraging results with respect to local control, complication risks and functional outcome.

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Abbreviations

CT:

Computertomographie

EKB:

Extrakorporale Bestrahlung

MRI:

„magnetic resonance imaging“

MRT:

Magnetresonanztomographie

MSTS:

Musculo-Skeletal Tumor Society

TESS:

Toronto Extremity Salvage Score

Literatur

  1. Aljassir F, Beadel GP, Turcotte RE et al (2005) Outcome after pelvic sarcoma resection reconstructed with saddle prosthesis. Clin Orthop Relat Res 438:36–41

    Article  PubMed  Google Scholar 

  2. Araki N, Myoui A, Kuratsu S et al (1999) Intraoperative extracorporeal autogenous irradiated bone grafts in tumor surgery. Clin Orthop Relat Res 368:196–206

    Article  Google Scholar 

  3. Bastian L, Hufner T, Mossinger E et al (2003) Integration of modern technologies in therapy of sarcomas of the pelvis. Computer-assisted hemipelvectomy and implantation of a „custom-made“ Bonit gentamycin coated partial pelvic prosthesis. Unfallchirurg 106:956–962

    CAS  PubMed  Google Scholar 

  4. Beadel GP, McLaughlin CE, Wunder JS et al (2005) Outcome in two groups of patients with allograft-prosthetic reconstruction of pelvic tumor defects. Clin Orthop Relat Res 438:30–35

    Article  PubMed  Google Scholar 

  5. de Boer HH, Wood MB (1989) Bone changes in the vascularised fibular graft. J Bone Joint Surg Br 71:374–378

    PubMed  Google Scholar 

  6. Cara JA, Laclériga A, Canadell J (1994) Intercalary bone allografts: 23 tumor cases followed for 3 years. Acta Orthop 65:42–46

    Article  CAS  Google Scholar 

  7. Chen TH, Chen WM, Huang CK (2005) Reconstruction after intercalary resection of malignant bone tumours: comparison between segmental allograft and extracorporeally-irradiated autograft. J Bone Joint Surg Br 87:704–709

    Article  CAS  PubMed  Google Scholar 

  8. Delloye C, Banse X, Brichard B et al (2007) Pelvic reconstruction with a structural pelvic allograft after resection of a malignant bone tumor. J Bone Joint Surg Am 89:579–587

    PubMed  Google Scholar 

  9. Donati D, Capanna R, Campanacci D et al (1993) The use of massive bone allografts for intercalary reconstruction and arthrodeses after tumor resection. A multicentric European study. Chir Organi Mov 78:81

    CAS  PubMed  Google Scholar 

  10. Donati D, Colangeli M, Colangeli S et al (2008) Allograft-prosthetic composite in the proximal tibia after bone tumor resection. Clin Orthop Relat Res 466:459–465

    Article  PubMed  PubMed Central  Google Scholar 

  11. von Eisenhart-Rothe R, Toepfer A, Salzmann M et al (2011) Primär maligne Knochentumoren. Orthopäde 40:1121–1142

    Article  Google Scholar 

  12. Falkinstein Y, Ahlmann ER, Menendez LR (2008) Reconstruction of type II pelvic resection with a new peri-acetabular reconstruction endoprosthesis. J Bone Joint Surg Br 90:371–376

    Article  CAS  PubMed  Google Scholar 

  13. Flege S, Kuhlen M, Paulussen M et al (2003) Operative Therapie primär maligner Knochentumoren. Orthopäde 32:940–948

    Article  CAS  PubMed  Google Scholar 

  14. Fox EJ, Hau MA, Gebhardt MC et al (2002) Long-term followup of proximal femoral allografts. Clin Orthop Relat Res 397:106–113

    Article  Google Scholar 

  15. Gebert C, Gosheger G, Winkelmann W (2009) Hip transposition as a universal surgical procedure for periacetabular tumors of the pelvis. J Surg Oncol 99:169–172

    Article  PubMed  Google Scholar 

  16. Gebert C, Wessling M, Hoffmann C et al (2011) Hip transposition as a limb salvage procedure following the resection of periacetabular tumors. J Surg Oncol 103:269–275

    Article  PubMed  Google Scholar 

  17. Griesser MJ, Gillette B, Crist M et al (2012) Internal and external hemipelvectomy or flail hip in patients with sarcomas: quality-of-life and functional outcomes. Am J Phys Med Rehabil 91:24–32

    Article  PubMed  Google Scholar 

  18. Hamer AJ, Strachan JR, Black MM et al (1996) Biochemical properties of cortical allograft bone using a new method of bone strength measurement. A comparison of fresh, fresh-frozen and irradiated bone. J Bone Joint Surg Br 78:363–368

    CAS  PubMed  Google Scholar 

  19. Hardes J, Gebert C, Schwappach A et al (2006) Characteristics and outcome of infections associated with tumor endoprostheses. Arch Orthop Trauma Surg 126:289–296

    Article  CAS  PubMed  Google Scholar 

  20. Hoffmann C, Gosheger G, Gebert C et al (2006) Functional results and quality of life after treatment of pelvic sarcomas involving the acetabulum. J Bone Joint Surg Am 88:575–582

    CAS  PubMed  Google Scholar 

  21. Hong A, Stevens G, Stalley P et al (2001) Extracorporeal irradiation for malignant bone tumors. Int J Radiat Oncol Biol Phys 50:441–447

    Article  CAS  PubMed  Google Scholar 

  22. Hong A, Millington S, Ahern V et al (2013) Limb preservation surgery with extracorporeal irradiation in the management of malignant bone tumor: the oncological outcomes of 101 patients. Ann Oncol 24:2676–2680

    Article  CAS  PubMed  Google Scholar 

  23. Krieg AH, Hefti F (2007) Reconstruction with non-vascularised fibular grafts after resection of bone tumours. J Bone Joint Surg Br 89:215–221

    Article  CAS  PubMed  Google Scholar 

  24. Krieg A, Lenze U, Gaston M et al (2010) The outcome of pelvic reconstruction with non-vascularised fibular grafts after resection of bone tumours. J Bone Joint Surg Br 92:1568

    Article  CAS  PubMed  Google Scholar 

  25. Krieg AH, Davidson AW, Stalley PD (2007) Intercalary femoral reconstruction with extracorporeal irradiated autogenous bone graft in limb-salvage surgery. J Bone Joint Surg Br 89:366–371

    Article  CAS  PubMed  Google Scholar 

  26. Krieg AH, Mani M, Speth BM et al (2009) Extracorporeal irradiation for pelvic reconstruction in Ewing’s sarcoma. J Bone Joint Surg Br 91:395–400

    Article  CAS  PubMed  Google Scholar 

  27. Longhi A, Ferrari S, Tamburini A et al (2012) Late effects of chemotherapy and radiotherapy in osteosarcoma and ewing sarcoma patients. Cancer 118:5050–5059

    Article  PubMed  Google Scholar 

  28. Mottard S, Grimer R, Abudu A et al (2012) Biological reconstruction after excision, irradiation and reimplantation of diaphyseal tibial tumours using an ipsilateral vascularised fibular graft. J Bone Joint Surg Br 94:1282–1287

    Article  CAS  PubMed  Google Scholar 

  29. Muramatsu K, Ihara K, Hashimoto T et al (2007) Combined use of free vascularised bone graft and extracorporeally-irradiated autograft for the reconstruction of massive bone defects after resection of malignant tumour. J Plast Reconstr Aesthet Surg 60:1013–1018

    Article  PubMed  Google Scholar 

  30. Ozaki T, Hillmann A, Bettin D et al (1996) High complication rates with pelvic allografts. Experience of 22 sarcoma resections. Acta Orthop Scand 67:333–338

    Article  CAS  PubMed  Google Scholar 

  31. Phieffer LS, Goulet JA (2006) Delayed unions of the tibia. J Bone Joint Surg Am 88:205–216

    Article  Google Scholar 

  32. Sabo D, Brocai DR, Eble M et al (2000) Influence of extracorporeal irradiation on the reintegration of autologous grafts of bone and joint. Study in a canine model. J Bone Joint Surg Br 82:276–282

    Article  CAS  PubMed  Google Scholar 

  33. Sabo D, Bernd L, Buchner M et al (2003) Intraoperative extrakorporale Irradiation und Replantation (IEIR) in der lokalen Behandlung primär maligner Knochentumoren. Orthopäde 32:1003–1012

    Article  CAS  PubMed  Google Scholar 

  34. Sakuraba M, Kimata Y, Iida H et al (2005) Pelvic ring reconstruction with the double-barreled vascularized fibular free flap. Plast Reconstr Surg 116:1340–1345

    Article  CAS  PubMed  Google Scholar 

  35. Singh VA, Nagalingam J, Saad M et al (2010) Which is the best method of sterilization of tumour bone for reimplantation? A biomechanical and histopathological study. Biomed Eng Online 9:48

    Article  PubMed  PubMed Central  Google Scholar 

  36. Spira E, Lubin E (1968) Extracorporeal irradiation of bone tumors. A preliminary report. Isr J Med Sci 4:1015–1019

    CAS  PubMed  Google Scholar 

  37. Strong DM, Friedlaender GE, Tomford WW et al (1996) Immunologic responses in human recipients of osseous and osteochondral allografts. Clin Orthop Relat Res 326:107–114

    Article  Google Scholar 

  38. Thompson R Jr, Pickvance E, Garry D (1993) Fractures in large-segment allografts. J Bone Joint Surg Am 75:1663

    Article  PubMed  Google Scholar 

  39. Unwin PS, Cannon SR, Grimer RJ et al (1996) Aseptic loosening in cemented custom-made prosthetic replacements for bone tumours of the lower limb. J Bone Joint Surg Br 78:5–13

    CAS  PubMed  Google Scholar 

  40. Weiland AJ, Moore JR, Daniel RK (1983) Vascularized bone autografts. Experience with 41 cases. Clin Orthop Relat Res (174):87–95. PMID: 6339145

    Google Scholar 

  41. Windhager R, Karner J, Kutschera HP et al (1996) Limb salvage in periacetabular sarcomas: review of 21 consecutive cases. Clin Orthop Relat Res 331:265–276

    Article  Google Scholar 

  42. Windhager R, Welkerling H, Kastner N et al (2003) Operative Therapie am Becken und an der Wirbelsäule bei primär malignen Knochentumoren. Orthopäde 32:971–982

    Article  CAS  PubMed  Google Scholar 

  43. Wirbel RJ, Schulte M, Mutschler WE (2001) Surgical treatment of pelvic sarcomas: oncologic and functional outcome. Clin Orthop Relat Res 390:190–205

    Article  Google Scholar 

  44. Yu G, Zhang F, Zhou J et al (2007) Microsurgical fibular flap for pelvic ring reconstruction after periacetabular tumor resection. J Reconstr Microsurg 23:137–142

    Article  PubMed  Google Scholar 

  45. Zehr RJ, Enneking WF, Scarborough MT (1996) Allograft-prosthesis composite versus megaprosthesis in proximal femoral reconstruction. Clin Orthop Relat Res (322):207–223. PMID: 8542698

    Article  Google Scholar 

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Danksagung

Ich möchte mich mit diesem Artikel bei Paul Stalley, FRCS, Leiter des Sarkomzentrums in Sydney, für seine Unterstützung und die Möglichkeit bedanken, diese Technik erlernen zu dürfen. Dank auch an meinen ehemaligen Chef und Mentor Prof. Dr. Fritz Hefti, der es mir ermöglichte, als junger Oberarzt diese Technik in Basel einzuführen und somit unser operatives Spektrum am Sarkomzentrum in Basel (KWUB) zu erweitern. Des Weiteren gebührt meinen Kollegen Prof. Dr. Martin Haug (Plastische Chirurgie) und Prof. Dr. Ludwig Plasswilm/PD Dr. Markus Gross (Radioonkologie) mit ihren jeweiligen Teams für die Unterstützung und die erfolgreiche Umsetzung dieser Technik größter Dank. Herrn Dr. Ulrich Lenze und Prof. Dr. F. Hefti danke ich herzlichst für die kritische Durchsicht des Manuskriptes.

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Authors and Affiliations

  1. Knochen- und Weichteiltumorzentrum der Universität Basel (KWUB), Kinderorthopädie, Universitätskinderspital beider Basel (UKBB), Spitalstr. 33, 4056, Basel, Schweiz

    A. H. Krieg

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Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Krieg, A.H. Die extrakorporale Bestrahlung. Orthopäde 46, 681–687 (2017). https://doi.org/10.1007/s00132-017-3445-z

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