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The Combined Use of Cryopreserved Recycled Bone and Free Vascularised Fibula Graft in Limb-Salvage Surgery: The Bone in the Bun Technique (Hot Dog Technique)Harzem Ozger, Mustafa Sungur, Bugra Alpan, Alauddin Kochai, Levent EralpIstanbul University Istanbul Faculty of Medicine Department of Orthopsedics and Traumatology1

? Amputation ? Rotationplasty ? Megaprosthesis ? Biological reconstruction ?Massive allograftRecycled bone: Autoclaving Irradiation Pasteurization CryopreservationFVFGCompositesMassive allograft + FVFGRecycled bone + FVFGThere are many ways to repair a bone defect but our preferred method for biological reconstruction is combination of cryopreserved bone and free vascular fibula graft. 2Massive Allograft - alone

6 yo male, ESProximal 2/3 of femur10 yrs follow-upNED

Early postop. Xray.Mass. allograft fixed w/ IM nail+3 yrs Antiobiotic rod due to infection +2 yrsExtracortical bone bridging but no unionAllograft removed due to infectionAvascularConsolidation too lateExpensiveImmune responseInfectionResorptionAvailabilitySocioreligious problemsAnatomical incongruencyDisadvantagesAdvantagesPrimary mechanical strength goodEwing sarcoma of 2/3 proximal femur. Reconstructed with massive allograft. good primary mechanical strength but no blood supply. Consolidation takes too long. May end up as sequestrum. 3Free Vascularized Fibular Graft - alone14 f, ESFVFG alone!+ 7 yrs follow-upNED

4 yrs for full consolidation and full weight bearing TOO LONGAdvantages- Easily available Vascular Rapid healing Disadvantages Primary mechanical strength insufficientEwings sarcoma of the proximal femur.Vascularised fibula alone. Rapid healing but sufficient mechanical strength takes 4 years - too long.

4WHYFROZENHOT DOG?Recycled Bone - cryopreservation Availability Anatomical congruence Autogenous proteins, growth factors, cytokines Almost no cost (only recycling cost) No immune reaction? (cryoimmunological function?)

Mechanical strength:Cryopreserved intact boneSuperiorities of cryopreservation: mechanical strength comparable to intact boneeasy availability,less expensive, perfect anatomical congruencebetter osteoinductive and osteoconductive properties. 6LN + FVFG = bone in the bunTechnique1. Tumor resection 2. Harvesting of FVFG3. Soft tissue stripping4. Preparation of medullary cavity 5. Preparation of cortical window for FVFG pedicle

6. Liquid Nitrogen treatmentNitrogen tank20 minRoom temperature (20)15 minHeated saline solution (30).....10 min7. Reimplantation + osteosynthesis8. Insertion of FVFG inside prepared bone segment and anastomosis of pedicle9. Grafting of osteotomy sites

tumor resectionsoft tissue strippingLN treatmentbone in the bun!

or hot dog

The stages of preparation of bone in the bun or hot dog

7Patients and Methods14 patients, treated between 2005-20098 male, 6 femaleMean age: 13.9 yrs (6-31)Mean follow-up: 17.1 months (6-46)9 osteosarcoma, 5 Ewing sarcomaTumor localization: - distal femur, 8 pts - proximal femur, 2 pts - femur diaphysis: 1 pt, - proximal tibia: 2 pts - tibia mid-diaphysis: 1 pt

10 yo male, OSDistal femur18 mo. follow-upNED

+ 17 mo. 14 patientsMean follow-up: 17.1 months 8Patients and MethodsRecycled bone: cryopreservation for all patientsFVFG: - 11 patients: contralateral single strut - 2 patients: bilateral fibula grafts harvested to bridge a defect longer than single fibula - 1 patient: ipsilateral single strutMean bony defect: 17.2 cm (9.0-27.5)Mean fibular graft length: 18.9 cm (10-28)Plate: 13 pts; IM nail: 1 pt.

10 m, OSProximal 2/3 femur43 mo.follow-upNED

+ 5 mo.+ 27 mo.+30 mo.For 2 patients we used bilateral fibula grafts to bridge a defect longer than single fibula 9ResultsComplete consolidation: 8 patientsMean time for consolidation: 13.4 months (9-19)

5 patients awaiting consolidation -mean follow-up: 7.6 months (6-12)No union in 1 pt (29 months follow-up; intramedullary nail)

Complications: - implant failure: 3 pts - local recurrence: 1 pt. ( non respondingto tx, synchron. multi-met) - deep infection: 1 pt (complete healing w/ antib., debr. + VAC)

19 female, OSDistal femur

10 male, ESDistal femurFull wt bearing and very good knee ROM at 15 mo. postopMean time for consolidation: 13.4 monthsOur complications are - implant failure in 3 patients - local recurrence in 1 patient. Did not respond to treatment, had synchronous multiple-mets. - deep infection in 1 patient which completely healed with treatment

10Bone in the bun8 yo. , OSGLN + FVFG24 mo. follow-upNED

+ 2 mo.+ 11 mo.+ 19 mo.+ 24 mo.+ 7 mo.osteosarcoma of distal femur Reconstructed with HOTDOG technique. Plate was broken at 11 months and revision was performed. Full consolidation at 19 months11Bone in the bun

+ 5 mo+ 20 mo.

14 yo. , ESLN + FVFG23 mo. follow-upNED

+ 17 monthsEwings sarcoma of proximal tibia. Another HOTDOG application. Knee functions at 17 months postop. Full consolidation at 20 months postop.

12Bone in the bun12 yo. , OSGLN + double FVFG17 mo. follow-upDOD

+ 0 mo.+ 3 mo.+ 13 mo.+ 13 mo.

Osteosarcoma of distal femur. Length of single fibula was not enough so reconstructed with two fibulas.13

Bone in the bun11 , ESHealed pathological fxLN + double FVFG+ 6 mo follow-upNED

Ewing sarcoma of femur presented with pathological fracture. 28 cm. bone segment was resected. 14

Bone in the bun

RRBone scan at 3 mo. postopshows good uptake,FVFGs are alive.+ 5 mo.

Two fibular grafts used for reconstruction. Recycled bone had to be osteotomized due to deformity. 15Conclusion Cryopreserved recycled bone:- readily available- cheap- anatomically congruent - good mechanical strengthBUT

- DEAD bone - prolonged consolidation time

Cryopreserved recycled bone is strong but dead16ConclusionFVFG:- LIVING bone- rapid unionBUT

- poor mechanical strength

Vascularized fibula graft is alive but weak17SolutionCombination (HOTDOG)

- faster consolidation- greater mechanical strength

Hotdog is strong and alive thank you for your attention18Thank you for your attention19