Defektrekonstruktion bei Tumoren des Knochens und der Gelenke

M. R. Sarkar; L. Kinzl; E. Hartwig

doi:10.1055/s-2003-43125

Aktuelle Traumatologie, Inhaltsverzeichnis

Aktuelle Traumatol 2003; 33(5): 215-227
DOI: 10.1055/s-2003-43125

Übersicht

Georg Thieme Verlag Stuttgart · New York

Defektrekonstruktion bei Tumoren des Knochens und der Gelenke

Reconstruction of Osseous Defects in Tumours of the Bone and JointsM. R. Sarkar¹ , L. Kinzl¹ , E. Hartwig¹

¹Abteilung für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Ulm

Abstract

Zusammenfassung

Im Rahmen der Behandlung von Knochentumoren entstehen häufig Defekte, die einer Rekonstruktion bedürfen, da sie aufgrund ihrer Größe nicht spontan überbrückt werden. Dabei sind rekonstruktive Überlegungen nachrangig gegenüber den onkologischen Erfordernissen, die sich aus der histologischen Artdiagnose des Tumors, dessen Größe und Lokalisation ergeben. Für einen biologischen Defektaufbau werden autogene oder allogene Knochentransplantate eingesetzt, erstere bei langstreckigem Ersatz auch mit der Option einer vaskulären Anastomosierung. Bei diaphysärer Lokalisation stellt die Kallusdistraktion eine Alternative dar. Knochenersatzmaterialien gewinnen in den letzten Jahren an Bedeutung, erreichen aber noch nicht die biologische Wertigkeit von Transplantaten. Osteoinduktive Proteine befinden sich im Stadium der klinischen Erprobung. Ist eine biologische Wiederherstellung nicht zu erreichen, kommen Endoprothesen, Arthrodesen oder Gelenkresektionen ohne Ersatz in Betracht. Die Abwägung zwischen Extremitätenerhalt und Amputation wird weniger aufgrund der Größe des knöchernen Defektes, sondern abhängig von der Aggressivität und der Ausdehnung der Weichteilkomponente getroffen, da bei malignen Tumoren die Erzielung tumorfreier Absetzungsränder das entscheidende prognostische Kriterium darstellt. Besondere Therapiekonzepte gelten für die Wirbelsäule und das Becken sowie für die Metastasenchirurgie. Eine verantwortungsvolle Indikationsstellung zu einem bestimmten Rekonstruktionsverfahren ist nicht ohne Kenntnis des onkologischen Gesamtkonzeptes möglich.

Abstract

Operative therapy of skeletal neoplasms frequently includes reconstructive measures, since resulting major osseous defects are not bridged spontaneously. However, restoring skeletal integrity has to be compatible with oncological requirements based on histology, size and location of the tumour. For biological reconstruction, autografts and allografts are preferred including vascularised intercalary autografts. In diaphyseal defects distraction osteogenesis has been employed successfully. Bone substitute materials have gained increasing interest. However, so far their potential does not match that of bone grafts. Osteoinductive, morphogenetic proteins are still under clinical investigation. In cases where biological reconstruction is not feasible, alternative methods are joint replacement, arthrodesis or joint resection. Limb salvage depends less on defect size than on aggressiveness of the lesion and soft tissue involvement since in malignant tumours safe surgical margins are crucial for patient survival. Special therapeutic approaches apply for spinal and pelvic tumours as well as for metastatic lesions. Skeletal reconstruction in tumour surgery depends on a thorough knowledge of the underlying oncological therapy concepts.

Volltext

Referenzen

Literatur

1 Aldinger G, Herr G, Küsswetter W, Reis H J, Thielemann F W, Holz U. Bone morphogenetic protein: a review. Int Orthop. 1991; 15 169-177
2 Alektiar K M, Leung D, Zelefsky M J, Healey J H, Brennan M F. Adjuvant brachytherapy for primary high-grade soft tissue sarcoma of the extremity. Ann Surg Oncol. 2002; 9 48-56
3 Altermatt S, Schwobel M, Pochon J P. Operative treatment of solitary bone cysts with tricalcium phosphate ceramic. A 1 to 7 year follow-up. Eur J Pediatr Surg. 1992; 2 180-182
4 Arrington E D, Smith W J, Chambers H G, Bucknell A L, Davino N A. Complications of iliac crest bone graft harvesting. Clin Orthop. 1996; 329 300-309
5 Bandiera S, Gasbarrini A, De Iure F, Cappuccio M, Picci P, Boriani S. Symptomatic vertebral hemangioma: the treatment of 23 cases and a review of the literature. Chir Organi Mov. 2002; 87 1-15
6 Bielack S, Kempf-Bielack B, Schwenzer D. et al . Neoadjuvante Therapie des lokalisierten Osteosarkoms der Extremitäten. Erfahrungen der Cooperativen Osteosarkomstudiengruppe COSS an 925 Patienten. Klin Pädiatr. 1999; 211 260-270
7 Briem D, Linhart W, Lehmann W, Meenen N, Rueger J M. Langzeitergebnisse nach Anwendung einer porösen Hydroxylapatitkeramik (Endobon) zur operativen Versorgung von Tibiakopffrakturen. Unfallchirurg. 2002; 105 128-133
8 Brooks A D, Gold J S, Graham D. et al . Resection of the sciatic, peroneal, or tibial nerves: assessment of functional status. Ann Surg Oncol. 2002; 9 41-47
9 Campanacci M, Capanna R, Picci P. Unicameral and aneurysmal bone cysts. Clin Orthop Rel Res. 1986; 204 25-36
10 Campanacci M, Ruggieri P, Gasbarrini A, Ferraro A, Campanacci L. Osteoid osteoma. Direct visual identification and intralesional excision of the nidus with minimal removal of bone. JBJS (Br). 1999; 81 B 814-820
11 Casadei R, Ruggieri P, Giuseppe T, Biagini R, Mercuri M. Ankle resection arthrodesis in patients with bone tumors. Foot & Ankle International. 1994; 15 242-249
12 Chow L C. Calcium-Phosphat-Zemente: Eigenschaften und Verwendungen. Biomaterialien. 2001; 2 11-18
13 Claes L E, Hoellen I P, Ignatius A. Resorbierbare Knochenzemente. Orthopäde. 1997; 26 459-462
14 Clohisy J C, Mankin H J. Osteoarticular allografts for reconstruction after resection of a musculoskeletal tumor in the proximal end of the tibia. JBJS (Am). 1994; 76 A 549-554
15 Cotteril S J, Ahrens S, Paulussen M. et al . Prognostic factors in Ewing's tumor of bone: analysis of 975 patients from the European Intergroup Cooperative Ewing's Sarcoma Study Group. J Clin Oncol. 2000; 18 3108-3114
16 Deijkers R LM, Bouma G J, van der Meer-Prins E MW, Huysmans P E, Taminiau A HM, Claas F HJ. Human bone allografts can induce T cells with high affinity for donor antigens. JBJS (Br). 1999; 81 B 538-544
17 Donati D, diLiddo M, Zavatta M. et al . Massive bone allograft reconstruction in high-grade osteosarcoma. Clin Orthop. 2000; 377 186-194
18 Durr H R, Maier M, Jansson V, Baur A, Refior H J. Phenol as an adjuvant for local control in the treatment of giant cell tumour of the bone. Eur J Surg Oncol. 1999; 25 610-618
19 Ekkernkamp A, Muhr G, Lies A. Die kontinuierliche Dekompression. Ein neuer Weg in der Behandlung juveniler Knochenzysten. Unfallchirurg. 1990; 93 539-543
20 Enneking F K, Campanacci D. Retrieved human allografts. JBJS [Am]. 2001; 83 A 971-986
21 Enneking (Hrsg) W F. Clinical musculoskeletal pathology. Gainesville; University of Florida Press 1993
22 Enneking W F, Spanier S S, Goodman M A. A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop. 1980; 153 106-120
23 Feigenberg S J, Marcus R BJ, Zlotecki R A, Scarborough M T, Berrey B H, Enneking W F. Megavoltage radiotherapy for aneurysmal bone cysts. Int J Radiat Oncol Biol Phys. 2001; 49 1243-1247
24 Fourney D R, Abi-Said D, Rhines L D. et al . Simultaneous anterior-posterior approach to the thoracic and lumbar spine for the radical resection of tumors followed by reconstruction and stabilization. J Neurosurg. 2001; 94 232-244
25 Friedlaender G E, Perry C R, Cole J D. et al . Osteogenic protein-1 (bone morphogenetic protein-7) in the treatment of tibial nonunions. JBJS [Am]. 2001; 83 A (Suppl 1) 151-158
26 Fuhrmann R A, Roth A, Venbrocks R A. Salvage of the upper extremity in cases of tumorous destruction of the proximal humerus. J Cancer Res Clin Oncol. 1999; 126 337-344
27 Gebhardt M C, Flugstad D I, Springfield D S, Mankin H J. The use of bone allografts for limb salvage in high-grade extremity osteosarcoma. Clin Orthop. 1991; 270 181-196
28 Gerhart T N, Kirker-Head C A, Kriz M J. et al . Healing segmental femoral defects in sheep using recombinant human bone morphogenetic protein. Clin Orthop. 1993; 293 317-326
29 Gibbs C PJ, Hefele M C, Peabody T D, Montag A G, Aithal V, Simon M A. Aneurysmal bone cyst of the extremities. Factors related to local recurrence after curettage with a high-speed burr. JBJS (Am). 1999; 81 A 1671-1678
30 Gosheger G, Hillmann A, Lindner N. et al . Soft tissue reconstruction of megaprostheses using a trevira tube. Clin Orthop Rel Res. 2001; 393 264-271
31 Gosheger G, Winkelmann W. Mutars - ein modulares Tumor- und Revisionssystem. Erfahrungen am Tumorzentrum Münster. Orthopäde. 2000; 29 (Suppl 1) S54-S55
32 Han C S, Wood M B, Bishop A T, Cooney W P. Vascularized bone transfer. JBJS (Am). 1992; 74 A 1441-1449
33 Hennen J, Sabo D, Martini A K, Bernd L. Das Manteltransplantat zur Defektrekonstruktion nach Resektion maligner Knochentumoren an der unteren Extremität. Unfallchirurg. 2002; 105 120-127
34 Hofmann G O, Falk C, Wangemann T. Immunological transformations in the recipient of grafted allogeneic human bone. Arch Orthop Trauma Surg. 1997; 116 143-150
35 Hofmann G O, Kirschner M H, Gonschorek O, Bühren V. Überbrückung langstreckiger Knochen- und Gelenkdefekte durch allogene vaskularisierte Transplantate. Unfallchirurg. 1999; 102 458-465
36 Hofmann G O, Kirschner M H, Wangemann T, Falk C, Mempel W, Hammer C. Infections and immunological hazards of allogeneic bone transplantation. Arch Orthop Trauma Surg. 1995; 114 159-166
37 Holbein O, Neidlinger-Wilke C, Suger G, Kinzl L, Claes L E. Ilizarov callus distraction produces systemic bone cell mitogens. J Orthop Res. 1995; 13 629-638
38 Johnstone P A, Wexler L H, Venzon D J. et al . Sarcomas of the hand and foot: analysis of local control and functional result with combined modality therapy in extremity preservation. Int J Radiat Oncol Biol Phys. 1994; 29 735-745
39 Kapukaya A, Subasi M, Kandiya E, Özates M, Yilmaz F. Limb reconstruction with the callus distraction method after bone tumor resection. Arch Orthop Trauma Surg. 2000; 120 215-218
40 Kotz R. Tumorendoprothesen bei malignen Knochentumoren. Orthopäde. 1993; 22 160-166
41 Krepler P, Windhager R, Bretschneider W, Toma C D, Kotz R. Total vertebrectomy for primary malignant tumours of the spine. JBJS (Br). 2002; 84 712-715
42 Kurz L T, Garfin S R, Booth R E. Harvesting autogenous iliac bone grafts. A review of complications and techniques. Spine. 1989; 14 1324-1331
43 Lejeune F J, Kroon B B, DiFilippo F. et al . Isolated limb perfusion: the European experience. Surg Oncol Clin N Am. 2001; 10 821-832
44 Levine S A, Perin L A, Hayes D, Hayes W S. An evidence-based evaluation of percutaneous vertebroplasty. Manag Care. 2000; 9 56-60
45 Lindner N J, Ozaki T, Roedl R, Gosheger G, Winkelmann W, Wortler K. Percutaneous radiofrequency ablation in osteoid osteoma. JBJS (Br). 2001; 83 B 391-396
46 Lokiec F, Wientroub S. Simple bone cyst: etiology, classification, pathology, and treatment modalities. J Pediatr Orthop. 1998; 7 262-273
47 Malawer M M, Bickels J, Meller I, Buch R G, Henshaw R M, Kollender Y. Cryosurgery in the treatment of giant cell tumor. A long-term follow-up study. Clin Orthop Rel Res. 1999; 359 176-188
48 Malawer M M, Dunham W. Cryosurgery and acrylic comentation as surgical adjuncts in the treatment of aggressive (benign) bone tumors. Analyses of 25 patients below the age of 21. Clin Orthop Rel Res. 1991; 262 42-57
49 Marcove R C, Sheth D S, Takemoto S, Healey J H. The treatment of aneurysmal bone cyst. Clin Orthop Rel Res. 1995; 311 157-165
50 Maurer F, Ambacher T, Weller S. Zystische Knochenveränderungen. Ätiologie, Diagnostik, therapeutische Prinzipien und eigene Behandlungsergebnisse. Langenbecks Arch Chir. 1996; 381 165-174
51 Minami A, Kutsumi K, Takeda N, Kaneda K. Vascularized fibular graft for bone reconstruction of the extremities after tumor resection in limb-saving procedures. Microsurgery. 1995; 16 56-64
52 Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Rel Res. 1989; 249 256-264
53 Moreau M F, Gallois Y, Basle M F, Chappard D. Gamma irradiation of human bone allografts alters medullary lipids and releases toxic compounds for osteoblast-like cells. Biomaterials. 2000; 21 369-376
54 Nelson D A, Barker M E, Hamlin B H. Thermal effects of acrylic cementation at bone tumour sites. Int J Hyperthermia. 1997; 13 287-306
55 Nilsonne U. Limb-preserving radical surgery for malignant bone tumors. Clin Orthop. 1984; 191 21-26
56 O'Connor M I, Sim F H, Chao E YS. Limb salvage for neoplasms of the shoulder girdle. JBJS (Am). 1996; 78 A 1872-1888
57 O'Donnell R J, Springfield D S, Motwani H K, Ready J E, Gebhardt M C, Mankin H J. Recurrence of giant-cell tumors of the long bones after curettage and packing with cement. JBJS (Am). 1994; 76 A 1827-1833
58 Olsson E, Andersson D, Brostrom L-A, Wallenstein R, Nilsonne U. Shoulder function after prosthetic replacement of proximal humerus. Ann Chir Gyn. 1990; 79 157-160
59 Ortiz-Cruz E J, Gebhardt M C, Jennings L C, Springfield D S, Mankin H J. The results of transplantation of intercalary allografts after resection of tumors. JBJS (Am). 1997; 79 A 97-106
60 Ozaki T, Hillmann A, Bettin D, Wuisman P, Winkelmann W. High complication rates with pelvic allografts. Experience of 22 sarcoma resections. Acta Orthop Scand. 1996; 67 333-338
62 Ozaki T, Hillmann A, Bettin D, Wuisman P, Winkelmann W. Intramedullary, antibiotic-loaded cemented, massive allografts for skeletal reconstruction. Acta Orthop Scand. 1997; 68 387-391
63 Ozaki T, Hillmann A, Wuisman P, Winkelmann W. Reconstruction of tibia by ipsilateral vascularized fibula and allograft. Acta Orthop Scand. 1997; 68 298-301
64 Ozaki T, Liljenqvist U, Halm H, Hillmann A, Gosheger G, Winkelmann W. Giant cell tumor of the spine. Clin Orthop. 2002; 401 194-201
65 Paulussen M, Ahrens S, Braun-Munzinger G. et al . EICESS 92 (European Intergroup Cooperative Ewing's Sarcoma Study) - Erste Ergebnisse. Klin Pädiatr. 1999; 211 276-283
66 Peltier L F, Bickel E Y, Lillo R, Thein M S. The use of plaster of paris to fill defects in bone. Ann Surg. 1957; 146 61-69
67 Pohlemann T, Gänsslen A, Hüfner T. Biomechanik und Pathobiomechanik. Tscherne H, Pohlemann T Becken und Azetabulum. Berlin; Springer 1998: 35-46
68 Porszolt F, Wirth A, Mayer-Steinacker R. et al . Quality assurance in oncology: definition of treatment goal and assessment of its achievement. Onkologie. 1994; 17 454-457
69 Rodl R, Pohlmann U, Gosheger G. et al . Ablative und extremitätenerhaltende Tumorchirurgie der unteren Extremität - Ein 10-Jahres-Vergleich. Z Orthop Ihre Grenzgeb. 2001; 139 183-188
70 Rodl R W, Pohlmann U, Gosheger G, Lindner N J, Winkelmann W. Rotationplasty - quality of life after 10 years in 22 patients. Acta Orthop Scand. 2002; 73 85-88
71 Rompe J D, Hopf C G, Eysel P. Outcome after palliative posterior surgery for metastatic disease of the spine - evaluation of 106 consecutive patients after decompression and stabilisation with the Cotrel-Dubousset instrumentation. Arch Orthop Trauma Surg. 1999; 119 394-400
72 Rougraff B T, Kling T J. Treatment of active unicameral bone cysts with percutaneous injection of demineralized bone matrix and autogenous bone marrow. JBJS (Am). 2002; 84 A 921-929
73 Rueger J M. Knochenersatzmittel - State of the art und: wohin gehen wir?. Unfallchirurg. 1996; 99 228-236
74 Rueger J M. Knochenersatzmittel. Heutiger Stand und Ausblick. Orthopäde. 1998; 27 72-79
75 Sabo D, Bernd L. Operative Therapie von Skelettmetastasen der Extremitäten. Orthopäde. 1998; 27 274-281
76 Sarkar M R, Schulte M, Bauer G, Hartwig E. Clinical results and organisational aspects of autogenous and allogenous bone grafting in the treatment of 226 patients with primary osseous neoplasms. Phillips GO, von-Versen R, Strong DM, Nather A Advances in Tissue Banking Vol. 1. Singapore; World Scientific 1997: 141-146
77 Sarkar M R, Schulte M, Bauer G, Hartwig E, v-Baer A. Primary bone and soft tissue tumours of the foot. Foot Ankle Surg. 1996; 2 261-270
78 Sarkar M R, Wachter N J, Patka P, Kinzl L. First histological observations on the incorporation of a novel calcium phosphate bone substitute material in human cancellous bone. J Biomed Mater Res (Appl Biomater). 2001; 58 329-334
79 Schiller C, Windhager R, Fellinger E J, Salzer-Kuntschik M, Kaider A, Kotz R. Extendable tumour endoprostheses for the leg in children. JBJS (Br). 1995; 77 B 608-614
80 Schmitz J P, Hollinger J O, Milam S B. Reconstruction of bone using calcium phosphate bone cements: a critical review. J Oral Maxillofac Surg. 1999; 57 1122-1126
81 Schnettler R, Dingeldein E, Herr G. Defektaufbau mit demineralisierter Knochenmatrix. Orthopäde. 1998; 27 80-88
82 Schratt H E, Regel G, Kiesewetter B, Tscherne H. HIV-Infektion durch kältekonservierte Knochentransplantate. Unfallchirurg. 1996; 99 679-684
83 Schulte M, Brecht-Krauss D, Werner M. et al . Evaluation of neoadjuvant therapy response of osteogenic sarcoma using FDG PET. J Nucl Med. 1999; 40 1637-1643
84 Schulte M, Hartwig E, Sarkar M R, v-Baer A. Risk-adapted surgery for skeletal metastasis in breast cancer. Rev Rhum (Engl Ed). 1998; 65 522
85 Schulte M, Hartwig E, Warszawski N, Sarkar M R, v-Baer A. Wie radikal muss die chirurgische Therapie ossärer Mammakarzinommetastasen sein?. Osteologie. 1996; 5 (Suppl) 54
86 Schulte M, Kinzl L, Mutschler W. Chirurgische Therapie von Wirbelmetastasen. Chirurg. 1992; 63 912-916
87 Shi H B, Suh D C, Lee H K. et al . Preoperative transarterial embolization of spinal tumor: embolization techniques and results. AJNR Am J Neuroradiol. 1999; 20 2009-2015
88 Simonds R J. HIV transmission by organ and tissue transplantation. AIDS. 1993; 7 S35-S38
89 Strong D M, Friedlaender G E, Tomford W W. et al . Immunologic responses in human recipients of osseous and osteochondral allografts. Clin Orthop. 1996; 326 107-114
90 Sundaresan N, Rothman A, Manhart K, Kelliher K. Surgery for solitary metastases of the spine: rationale and results of treatment. Spine. 2002; 27 1802-1806
91 Tiedemann J J, Garvin K L, Kile T A, Connolly J F. The role of a composite, demineralized bone matrix and bone marrow in the treatment of osseous defects. Orthopedics. 1995; 18 1153-1158
92 Tomford W W. Current concepts review: transmission of disease through transplantation of musculoskeletal allografts. JBJS (Am). 1995; 77 A 1742-1754
93 Trieb K, Bitzan P, Lang S, Dominkus M, Kotz R. Recurrence of curetted and bone-grafted giant-cell tumours with and without adjuvant phenol therapy. Eur J Surg Oncol. 2001; 27 200-202
94 Tsuchiya H, Tomita K, Shinokawa Y, Minematsu K, Katsuo S, Taki J. The Ilizarov method in the management of giant-cell tumours of the proximal tibia. JBJS (Br). 1996; 78 B 264-269
95 Uchida A, Araki N, Shino Y, Yoshikawa H, Kurisaki E, Ono K. The use of calcium hydroxyapatite ceramic in bone tumour surgery. JBJS (Br). 1990; 72 B 298-302
96 Urist M R. Bone: Formation by autoinduction. Science. 1965; 150 893-899
97 Vandeweyer E, Gebhart M. Complete fibular regeneration following removal of the fibula for bone grafting. Acta Chir Belg. 1996; 96 182-184
98 von Garrel T, Gotzen L. Allogene Knochentransplantation und Knochenbanking. Unfallchirurg. 1998; 101 713-727
99 Weigel B, Maghsudi M, Neumann C, Kretschmer R, Muller F J, Nerlich M. Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life. Spine. 1999; 24 2240-2246
100 Windhager R, Karner J, Kutschera H P, Polterauer P, Salzer-Kuntschik M, Kotz R. Limb salvage in periacetabular sarcomas: review of 21 consecutive cases. Clin Orthop. 1996; 331 265-276
101 Wippermann B, Schratt H E, Steeg S, Tscherne H. Komplikationen der Spongiosaentnahme am Beckenkamm. Chirurg. 1997; 68 1286-1291
102 Wissenschaftlicher Beirat der Bundesärztekammer . Richtlinien zum Führen einer Knochenbank. Dt Ärztebl. 2001; 98 A 1011-1016
103 Wunder J S, Leitch K, Griffin A M, Davis A M, Bell R S. Comparison of two methods of reconstruction for primary malignant tumors at the knee: a sequential cohort study. J Surg Oncol. 2001; 77 89-99
104 Yandow S M, Lundeen G A, Scott S M, Coffin C. Autogenic bone marrow injections as a treatment for simple bone cyst. J Pediatr Orthop. 1998; 18 616-620

OA Dr. M. R. Sarkar

Abteilung für Unfall-, Hand- und Wiederherstellungschirurgie
Universitätsklinikum Ulm

89070 Ulm

Telefon: 0731/500-0

Fax: 0731/500-27349

eMail: michael.sarkar@medizin.uni-ulm.de