Distraction Osteogenesis Reconstruction Following Resection of Bone Sarcomas: Surgical, Functional, and Oncological Outcomes from a Prospective Trial Analysis

Abstract

Background: While sustainable long-term function has been established for biological reconstruction with distraction osteogenesis (DO) following osseous resections, there is a paucity of published data informing surgeons and patients on important milestones in the reconstructive process. The objectives of this study were to determine when to expect complete bone healing and full weight-bearing as well as to quantify the influence of chemotherapy on the osseous regeneration process.

Methods: Prospectively, pathological and clinical data were collected for 30 consecutive patients who underwent primary or secondary DO-based reconstruction following osseous resection from 2018 to 2021. Serial radiographs indicated the times to cortex formation and full union. An unpaired t test was used to compare the time required for full bone remodeling of segments transported with and without concurrent chemotherapy.

Results: The average resection length was 13.6 cm (range, 4 to 22 cm). Patients underwent an average of 6.1 procedures (range, 1 to 14 procedures). Half (50%) of all procedures were planned, while half were unplanned procedures. All patients achieved full, independent weight-bearing at a median of 12 months (interquartile range [IQR], 9 to 16 months). For the 34 segments transported concurrently with chemotherapy, the mean bone healing index (BHI) was 2.3 ± 0.7, and the mean BHI was 1.2 ± 0.4 for the 25 segments without chemotherapy at any point during their transport (p < 0.0001).

Conclusions: All 30 patients achieved full bone healing and independent weight-bearing at a median of 1 year postoperatively and continued to show functional improvement afterward. Surgeons and patients can expect bone healing to be nearly twice as fast for segments transported after completion of systemic chemotherapy compared with segments transported concurrently with adjuvant chemotherapy.

Level of evidence: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Fig. 1

Figs. 1, 2, and 3 The distraction osteogenesis process visualized. A 14-year-old male patient with osteosarcoma of the right distal femur underwent plate-assisted bone segment transport (PABST) following a 23-cm osseous resection (A). While lengthening and docking proceeded uneventfully (B), a distal malunion with 30° external rotation developed (C). Correction of the deformity with a new intramedullary nail was performed, and the patient healed with equal limb lengths (D and E). The hardware was removed after bone healing was complete (F and G).

Fig. 2

A 10-year-old female patient with Ewing sarcoma of the left femur underwent dual segment transport with the PABST technique following a 17-cm osseous resection (A). Initially, the distal metaphysis was transported proximally using an intramedullary nail (B). Subsequently, a proximal segment was transported distally using a new intramedullary nail (C). When the docking site between these 2 segments failed to unite, a procedure was undertaken to debride the docking site and apply compression across it using another intramedullary nail (D). Docking-site union was then achieved, and the patient underwent 1 final lengthening procedure to address a limb-length discrepancy (E and F).

Fig. 3

A 9-year-old female patient with Ewing sarcoma of the left humerus experienced a pathological fracture (A). Following neoadjuvant chemotherapy and a 14.3-cm osseous resection, she underwent distraction osteogenesis with an external fixator and cables (B and C). Persistent nonunion (D) was treated with a reamed intramedullary nail (E). Union of the humerus was achieved, and a final lengthening from the humeral neck was initiated to address a limb-length discrepancy (F).

Fig. 4

Mean MSTS scores at baseline (just prior to initiation of distraction osteogenesis [DO]) and over time following DO. Error bars represent the standard deviation.