Biological Methods of Reconstruction After Excision of Extremity Osteosarcoma

Volume 2 | Issue 2 | May-Aug 2016 | Page 5-9 | Suman Byregowda, Ajay Puri, Ashish Gulia.

Authors: Suman Byregowda [1], Ajay Puri [1], Ashish Gulia [1].

1Orthopedic Oncology Services, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai.

Address of Correspondence
Dr. Ashish Gulia
Associate Professor, Orthopedic oncology, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai.


The overall survival rates for non-metastatic osteosarcomas have dramatically improved from a mere 15-20% to 60-65% today. This was possible due a multifactorial improvement in all the disciplines and specifically the advent of multiagent chemotherapy. With an exponential increase in the survival as well as limb salvage procedures, it would be customary to invent cost effective, stable, durable reconstruction options. Various biological and non biological methods are available for reconstruction. In the era of metal and with the advent of growing artificial bones, non biological options appear to be an attractive and easily available option with excellent immediate results but their long term results and complications are debatable. On the other hand the less attractive biological methods are known to provide stable, durable, cost effective reconstruction options. In the present article we discuss various biological reconstruction methods available for extremity osteosarcoma patients, their advantages and disadvantages.
Keywords: Biological reconstruction , Osteogenic sarcoma


The era when osteosarcomas of the extremity were treated with only amputations is long past and the advent of multimodality management has completely changed the outcomes of these tumors. With newer chemotherapic agents, modern surgical techniques, better imaging techniques and affordable reconstructive options limb salvage has become the norm resulting in better functional and psychological outcomes The prerequisites for limb salvage include the ability to achieve an oncologically safe margin and ability to reconstruct the limb such that it provide better function compared to an amputation. Today this is possible in more than 95% of the patients [1]. Adequate oncologic clearance is paramount and the chosen method of reconstruction should never compromise the amount of resection required. The barriers to limb salvage are encasement of a major motor nerve, major vascular involvement, poorly placed biopsy incisions, uncontrolled infection, displaced pathological fractures and inadequate motors after resection of tumors. Besides fulfilling the basic pre requisites of limb salvage mentioned above the reconstructive modality chosen should permit an early return to daily activities and be aesthetically acceptable. . The reconstruction must be durable, economically feasible and should have minimum short term and long term complications. A number of reconstructions methods, both biological and non biological are available for the reconstruction of these skeletal defects after resection. The chosen method of reconstruction should be tailored for the individual based on the growth potential, site and amount of resection and functional requirements. This article discusses the biological techniques available for reconstruction of bone defects after resection of an extremity osteosarcoma.

Biological methods available for reconstructions are
A) Allografts
B) Autografts – vascularised and non vascularised
C) Patient’s own sterilized tumor bone
D) Combination of allografts/ sterilized tumor bone and vascularised autografts
E) Distraction osteogenesis with Ilizarov technique
F) Rotationplasty
G) Masquelet technique
Depending on the extent of the resection, the surgical resections can be categorised as Osteo-articular resections and Intercalary resections. Reconstruction after osteoarticular resections is mainly done by megaprosthesis (non biological). If you want to retain joint mobility the biological options available are limited to osteoarticular allografts. Though these maintain bone stock and provide a better attachment for surrounding soft tissue resulting in increased stability of the construct the long term results with osteoarticular allografts are disappointing .Fracture, arthritis, non unions, infections and repeated surgery are not uncommon. Studies have reported 60-70 % adverse events, overall 5 year survival of 69 % and 79 % for allograft and articulate surface respectively[2,3]. A composite of allograft and prosthesis has been widely used, where allograft helps to maintain the stock and prosthesis provides the articular surface (Fig. 1).   The functional outcomes with composite reconstruction are comparable with prosthetic reconstruction alone but associated with higher complication like nonunion and fracture. This method can have limited use in selected young patients with expected long term survival and require good bone stock for revision surgeries [4,5,6]. Allografts require sophisticated bone banks for procurement and storage and these are not available in most of the developing countries. Bone donations are not as frequent as other organ donations making procuring of size matched allografts even more challenging. Allografts may also be associated with risk of transmission of disease. Though strut allografts alone can be used for the reconstruction of intercalary defects and knee arthrodesis but studies have shown higher rate of complication like fracture, non union and resorption of grafts. Study by Bus MP et al has demonstrated a complication rate of 76 % and 70 % chance for reoperation due to graft failure. Thus strut allografts alone have limited use and are generally preferred for the upper limb or small defects (< 15cms). To overcome the above complication strut allograft may be combined with vascular fibular grafts [7,8]. Fibula is the most widely used autograft for reconstruction. It can be used as a vascularised or non vascularised graft. Proximal fibular head (with articular surface) has been used to reconstruct the articular surface of proximal humerus and distal radius. While isolated vascularized fibula may be adequate for reconstruction of upper limb defects where weight bearing is not an issue, lower limb reconstructions involving femur or the knee generally require a combination of vascularised fibula with strut allografts (Fig 2). Isolated use of fibula autograft or strut allografts have higher failure rates in large lower limb bone defects [9,10,11]. Small osteoarticular defects (up to 5 cm) like after the resection of distal radius lesions can also be reconstructed with iliac crest autograft. Certain anatomical sites have an inherent advantage and ease for reconstruction. Use of the neighbouring bone in forearm and leg provides a vascularised graft after resection of the radius and tibia. This serves as an easy and effective method of reconstruction. Shifting the distal ulna after an osteotomy at an appropriate level into the defect along with its soft tissue attachment and stabilizing it to the radius proximally and carpal bone distally (wrist arthordesis) provides an excellent method of reconstructing the bone defects after resection of distal radius tumors (Fig. 3). This method provides a stable wrist while maintaining forearm rotations (pronation- supination)[12]. Similarly in tibial lesions the fibula is mobilized medially into tibial defect and stabilized. This can be done both, for intercalary resections of the tibia where fibula is shifted after a double osteotomy and distal intrarticular resections where the transposed fibula is stabilized to talus to create an ankle arthrodesis This procedures avoids the requirement of a complex micro vascular procedure, reduces the operative time and also facilitates ease of soft tissue closure as transportation of fellow bone in to the defect will result in volume reduction of the tissues [13]. Reimplanting sterilized tumor host bone is widely used after intercalary resections. Patients own resected bone is sterilized and used to fill the defect. The resected tumor grafts can be sterilized by various methods like radiotherapy (extra-corporeal radiotherapy), pasteurization, autoclaving, liquid nitrogen and microwave. This technique has various advantages over the use of allograft. It does not require a bone bank, provides size matched graft (as it has been taken from the same defect) and has no risk of transmitted disease. After resection of the tumor the tumor bearing bone is taken on a separate table and soft tissues are removed under aseptic precautions. Certain soft tissues like ligaments may be retained on the bone graft in order to facilitate reconstruction. Sterilized bones are implanted back in the defect and stabilized with intramedullary nails or plates (Fig. 4).  Reimplanted bone acts a scaffold for creeping substitution and incorporation. To enhance incorporation and the union at osteotomy sites they can be combined with a vasclarised fibula ( Capanna technique). Puri et al documented a mean union time of 7 months for osteotomy sites and an excellent MSTS score of 29 with extracorporeal radiotherapy [14,15]. To overcome the adverse events like nonunion, fracture and collapse with the use of liquid nitrogen to sterlise tumor bone (fresh frozen autograft), pedical autograft technique was developed. In this technique an osteotomy is done at one end or joint disarticulation done and the whole specimen is treated with liquid nitrogen with other end in continuity with the main bone. It is then stabilized back with internal fixation or athroplasty. As bony continuity is maintained at one end, it is presumed to have early blood flow recovery and faster union and less complication compared with frozen autograft [16,17]. The main drawback of sterilized bones are inadequate mechanical strength resulting in graft fracture and implant failure. To enhance incorporation and to overcome inadequate mechanical strength they can be combined with a vasclarised fibula ( Capanna technique). For surface lesions like periosteal, parosteal and high grade surface osteosarcomas where medullary canal is not involved, bone preserving hemicortical excision may be considered. Meticulous planning with MRI and CT scans are required to obtain adequate margins and preserve good native bone. Computer assisted navigation surgery is advantageous while performing such technically demanding bone preserving surgeries. Various options are available to fill the bone defect after hemicortical excision (sterlised resected bone, strut allografts or small defects can be filled with autografts) [18,19]. Rotationplasty involves converting ankle joint to knee joint by segmental resection and rotating the foot externally to 180 degrees. This is an alternative method for reconstruction especially in children with growth potential where cost constraints may preclude the use of expensive growing prosthesis. This worthies also useful in converting hind quarter or above knee amputations to a functional below knee like amputation in adult patients where conventional resection and reconstructions are not possible due to large or previously inappropriately treated lesions In distal femur and proximal tibia lesions, a segment of involved bone along with knee joint and involved soft tissues is removed only sparing the neurovascular bundle. Here the two segments are connected only with neurovascular bundle. The distal fragment is externally rotated 180 degrees and distal part of femur is stabilized to proximal tibia with appropriate implants, in such a way that the ankle comes to the level of opposite knee joint. In the cases with involvement of whole femur, proximal tibia is articulated with the hip joint with or without use of prosthesis after external 180 dgree rotation. Adequate soft tissue reconstructions and an intense rehabilitation protocol ensures an excellent functional outcome in these cases where the ankle will act like knee joint, dorsiflexion of ankle acts as flexion and plantar flexion acts as extension of knee joint (Fig. 5).  This procedure can also be used as salvage surgery following infected and failed limb salvage reconstruction. Studies have shown excellent oncological and functional outcome with this procedure. Rotationplasty offers a durable reconstruction option. It is not associated with phantom limb pain or sensations which are common following amputations. The main drawback of the procedure is the cosmetic deformity due to posterior rotated foot [20,21]. Distraction osteogensis using ilizarov method has been used for bone defects in tumor resection. It can be combined with live fibula grafts. The disadvantages are prolonged duration of treatment, high incidence of pin tract infections due to immune compromised state of patient receiving chemotherapeutic agents [22,23]. Due to these complications it is not a popular method and is used rarely. Masquelet technique is a two stage procedure for reconstruction of bone defects. In the first stage the defect is filled with bone cement and stabilized. This leads to the formation of a biological membrane over the cement spacer. In second stage procedure the biological membrane is opened, cement spacer removed, filled with cortico-cancellous bone graft and biological membrane sutured to create close content. The procedure was described in children. The ideal time for stage two is between 6 to 8 weeks, though in oncology we wait for completion of adjuvant treatment. Advantage is it makes primary surgery short and rapid uptake of graft due to biological membrane after the second procedure. The disadvantage with procedure is requirement of two surgical interventions [24].


Reconstruction following tumor resection is a challenging task. Different biological and non biological methods are available. Selection of a reconstruction procedure should be tailored to the individual patient based on the bone affected, amount of resection, requirement of patient and expertise and infrastructure available at treating centre. Biological methods are more cost effective and provide durable reconstruction options in properly selected extremity osteosarcoma patients.


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10. Campanacci DA, Puccini S, Caff G, Beltrami G, Piccioli A, Innocenti M, Capanna R. Vascularised fibular grafts as a salvage procedure in failed intercalary reconstructions after bone tumour resection of the femur. Injury. 2014 Feb;45(2):399-404.
11. Hilven PH, Bayliss L, Cosker T, Dijkstra PD, Jutte PC, Lahoda LU, Schaap GR, Bramer JA, van Drunen GK, Strackee SD, van Vooren J, Gibbons M, Giele H, van de Sande MA. The vascularised fibular graft for limb salvage after bone tumour surgery: a multicentre study. Bone Joint J. 2015 Jun;97-B(6):853-61.
12. Puri A, Gulia A, Agarwal MG, Reddy K. Ulnar translocation after excision of a Campanacci grade-3 giant-cell tumour of the distal radius: an effective method of reconstruction. J Bone Joint Surg Br. 2010 Jun;92(6):875-9.
13. Puri A, Subin BS, Agarwal MG. Fibular centralisation for the reconstruction of defects of the tibial diaphysis and distal metaphysis after excision of bone tumours. J Bone Joint Surg Br. 2009 Feb;91(2):234-9.
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17. Shimozaki S, Yamamoto N, Shirai T, Nishida H, Hayashi K, Tanzawa Y, Kimura H, Takeuchi A, Igarashi K, Inatani H, Kato T, Tsuchiya H. Pedicle versus free frozen autograft for reconstruction in malignant bone and soft tissue tumors of the lower extremities. J Orthop Sci. 2014 Jan;19(1):156-63.
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22. Demiralp B, Ege T, Kose O, Yurttas Y, Basbozkurt M. Reconstruction of intercalary bone defects following bone tumor resection with segmental bone transport using an Ilizarov circular external fixator. J Orthop Sci. 2014 Nov;19(6):1004-11.
23. Khira YM, Badawy HA. Pedicled vascularized fibular graft with Ilizarov external fixator for reconstructing a large bone defect of the tibia after tumor resection. J OrthopTraumatol. 2013 Jun;14(2):91-100.
24. Chotel F, Nguiabanda L, Braillon P, Kohler R, Bérard J, Abelin-Genevois K. Induced membrane technique for reconstruction after bone tumor resection in children: a preliminary study. OrthopTraumatolSurg Res. 2012 May;98(3):301-8.

How to Cite this article: Byregowda S, Puri A, Gulia A. Biological Methods of Reconstruction After Excision of Extremity Osteosarco. Journal of Bone and Soft Tissue Tumors May- Aug 2016;2(2):5-9 .


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Tata Memorial Centre – The Journey so Far!!!

Volume 2 | Issue 2 |May- Aug 2016 | Page 3-4 |  Ashish Gulia, Ajay Puri, Rajendra.A. Badwe

Authors:  Ashish Gulia [1], Ajay Puri [1], Rajendra.A. Badwe [1].

[1]Orthopedic Oncology Services, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai.

Address of Correspondence
Dr. Ashish Gulia
Associate Professor, Orthopedic oncology, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai.

Tata Memorial centre, considered as “Mecca” of Oncology care in the country and sub continent, stands today at its Dodranscentennial Anniversary. Institution started as Tata Memorial Hospital, which was inaugurated on 28th February 1941 by His Excellency Sir Roger Lumley, then Governor of Mumbai. Declaring the centre open, he estimated with extraordinary prescience “…the hospital will become the spearhead of attack on cancer in this country, providing not only a center where specialized treatment can be given, but also one from which knowledge of new methods of treatment and diagnosis will go out to doctors and hospitals throughout the country…”The past 75 years stand as glowing testimony to Sir Lumley’s prophecy. A recent peer group review of the hospital has accredited it as the premier comprehensive center in India, in addition recognized it as potentially and prominently featuring in the top five cancer centers globally. The advent of TMH in chapters of the history of medicine in India can best be defined as a quantum leap. It owed its genesis to the philanthropic sentiments of the illustrious Tata family. Later on, in 1961 was passed under the guardianship of Department of Atomic Energy which remarkably aided and upheld the meteoric rise of the sterling institution. In the year 1966 Tata Memorial Hospital merged with Cancer Research Institute (the pioneer research institute), the conjoined institutes were collectively called Tata Memorial Centre (TMC). TMC exemplifies private philanthropy boosted by Government support with a mandate for Service, Education & Research in Cancer. Commencing its journey as a torchbearer, the first dedicated cancer specialty hospital in Asia, TMC today continues to maintain its excellence of being the largest cancer institute in Asia. A fledgling 80 bedded hospital spread over 15,000 sq meters with an annual budget of half a million (INR), has escalated to a lofty institution with 700+ beds, covering over 75,000 sq meters, utilizing an annual budget of 23,00 million (INR). TMC indomitably bears the responsibility of cancer care burden not only of the large Indian populace but also several parts of Asia, Middle East and Africa, catering to an annual footfall of 65,000 new cases and 450,000 follow up cases.[1] Research and education have unarguably been the essential arms of a comprehensive cancer care centre. TMC since origin has embraced the holistic model of delivering cancer care by augmenting and developing its research and education facilities as it sought to provide treatment which was affordable, innovative and particularly relevant to the needs of the country. The research wing of TMC originally established in 1952 as CRI (Cancer Research Institute) was subsequently revamped as ACTREC (Advanced Centre for Treatment Research and Education in Cancer) in 2002. ACTREC is a state of art research and training centre which has over the years focussed on the integration of basic and clinical research including evolving inspiring pathways for translational research. The academic unit of TMC imparts training in specialty and super specialty courses in oncology and is affiliated to the acclaimed Homi Bhabha National Institute, Mumbai.[1]
The noble mission of the institute was to provide comprehensive cancer care to one and all. A practice which has been resolutely followed since its inception is, that every patient who walks in is attended to and treated irrespective of their ability to pay. Over 60% of TMC’s patients receive free or highly subsidized treatment. The essence of the center however, lies in its undeviating constancy towards extending compassionate care and assuaging suffering in times of extreme distress. Patients and caregivers often refer to the hospital as a temple which bespeaks diligence and dedication of the individuals who work there. As millions stream in seeking hope, this Mecca continually labors to ensure means of cure, care and cope. Seventy five glorious years of Tata Memorial Centre have borne witness to its commitment to excellence, expertise and eminence in cancer treatment, care, research, education and awareness. As a tribute to this iconic institution we mark a yearlong celebration of its Platinum Jubilee (Dodranscentennial Anniversary) 2016.[1] The appointment of a full time orthopaedic surgeon on the staff of Tata Memorial Centre in 1999 resulted in the establishment of a specialist orthopaedic oncology service [2]. Over the years this service has now grown to be recognised as one of the leading musculoskeletal oncology units globally. Like all other services at the centre this too functions as a “Disease Management Group”, where specialists from all disciplines involved in sarcoma care (radiology, pathology, medical oncology, radiation oncology, etc.) come together to provide multidisciplinary integrated care under one umbrella. Today the orthopaedic oncology service caters to about 2500 new musculoskeletal oncology cases per year while performing about 700 major and 1200 minor surgical procedures each year. The service has collaborated with industry to develop cost effective mechanical reconstructive options suited to the local socio economic milieu. The development of an indigenous prosthesis (TMH – NICE / RESTOR) which was recognised by the Golden Peacock award for health innovation is a proud feather in the cap of the institute. Innovative biological reconstruction techniques published in reputed peer reviewed journals are now practised in other centres globally too. Both clinical and basic research also plays a part in the units’ contribution to furthering insights in sarcoma care. The service has to its credit the only randomised trial ever conducted for surveillance in sarcomas and is part of a global consortium that has published one of the largest series of patients detailing the genomic profile of sarcomas. [3,4] Imparting training and sharing of knowledge and information has always been part of the culture of this institute and a host of young orthopaedic oncologists practising all across the country are a proud testimony in keeping with this tradition. There is a constant stream of international trainees and visitors and the service has helped in initiating and developing the limb salvage program in many resource challenged areas like Nepal, Myanmar, Palestine and Nigeria. [5] The TMC “Evidence Based Guidelines” for the management of bone and soft tissue sarcomas is a useful handbook that helps disseminate the concept of scientific and rational treatment for these challenging tumors. TMC staff and alumni have been at the forefront in establishing the Indian Musculo Skeletal Oncology Society (IMSOS), an organisation that seeks to provide a common forum for interaction and mutual collaboration between different specialists and institutes involved in the treatment of sarcomas. As the institute seeks to expand its footprint over the next decade by adding infrastructure and staff, both in Mumbai and centres across the country the orthopaedic oncology service too will need to evolve. Challenges of adopting new technology will have to be met. Yet, offering the right balance between these enhanced options while maintaining the principles of rational , cost effective medical care will necessitate “the wisdom of Solomon”.
Just as it has for the past 75 years, the institute and every individual connected with it will always strive with utmost passion to fulfil its motto of “Service – Education – Research” in a ceaseless endeavour to offer the best possible care to the patients that repose their trust in this institute.


1. Tata Memorial Centre. 2016. Tata Memorial Centre Platinum Jubilee – Celebrating 75 Glorious Years. Available at:
2. Puri A – The “ODYSSEY”: “Orthopaedic Oncology” – My journey thus far! Journal of Bone and Soft Tissue Tumors May-Aug 2015; 1(1):4-6
3. Puri A, Gulia A, Hawaldar R, Ranganathan P, Badwe RA. Does Intensity of Surveillance Affect Survival After Surgery for Sarcomas? Results of a Randomized Noninferiority Trial. ClinOrthopRelat Res. 2014 May;472(5):1568-75.
4. Ballinger ML, Goode DL, Ray-Coquard I, James PA, Mitchell G, Niedermayr E, Puri A, Schiffman JD, Dite GS, Cipponi A, Maki RG, Brohl AS, MyklebostO,Stratford EW, Lorenz S, Ahn SM, Ahn JH, Kim JE, Shanley S, Beshay V, Randall RL, Judson I, Seddon B, Campbell IG, Young MA, Sarin R, Blay JY, O’DonoghueSI,Thomas DM; International Sarcoma Kindred Study. Monogenic and polygenic determinants of sarcoma risk: an international genetic study. Lancet Oncol. 2016 Aug 4.
5. Gulia A, Wilding C, Suman MB, Puri A. OrthOncoCon-2014: Continuing education in musculoskeletal oncology. Indian J Cancer. 2015 Apr-Jun;52(2):184-5.

How to Cite this article:  Gulia A, Puri A, Badve, RA. Tata Memorial Centre – The Journey so Far!!!. Journal of Bone and Soft Tissue Tumors May- Aug 2016;2(2):3-4 .

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