International
International Orthopaedics (SlCOY) (1990) 14:249-253
Orthopaedics © Springer-Verlag 1990
Massive bone allografts in children R. Kohler 1, F. Lorge 1, M. Brunat-Mentigny 2, D. Noyer 3, and L. PatricoP JClinique Mutualiste, 107, rue Trarieux, F-69003 Lyon, France 2Centre Anticancereux Leon Berard, 28, rue La~nnec, F-69008 Lyon, France 3Laboratoire Anatomo-pathologique, H6pital Croix-Rousse, F-69004 Lyon, France
S u m m a r y . A group o f ten children and adolescents
with malignant bone tumours (eight osteosarcomas, two Ewing's tumours) were treated with chemotherapy and resection with allograft reconstruction. Intercalary grafts were used in three cases and terminal osteoartieular grafts at the knee in seven. The mean follow up was 22 months. Functional results were satisfactory, but there were some complications related to the graft. Although these are early results, we believe that the method is justified and is preferable to the use o f an endoprosthesis, particularly in children. R~sum~. Un groupe de dix enfants et adolescents
atteints de tumeurs osseuses malignes (huit ostdosarcomes, deux sarcomes d'Ewing) ont dtd traitds par chimiothbrapie et rbsection suivies d'une reconstruction par allogreffes. Des greffes intercalaires ont dtd utilisdes dans trois cas et des greffes terminales ostko-articulaires au niveau du genou dans sept cas. Le recul moyen est de 22 tools. Les rbsultats fonctionnels ont dtd satisfaisants, mais on a observb quelques complications en relation avec la greffe. Bien qu'il ne s'agisse ld que de rdsultats prbcoces, nous pensons que cette mdthode est justifide et qu'elle est prbf&able d l'utilisation d'endoprothOses, surtout chez les enfants.
Introduction W e r e p o r t o u r e x p e r i e n c e o f l i m b s a l v a g e b y res e c t i o n a n d a l l o g r a f t r e c o n s t r u c t i o n i n t e n child r e n a n d a d o l e s c e n t s w i t h m a l i g n a n t b o n e tum o u r s . T h i s d e v e l o p m e n t is d u e to the s p e c t a c u l a r
Offprint requests to: R. Kohler
p r o g r e s s i n c h e m o t h e r a p y o v e r t h e p a s t few y e a r s [4, 7, 13]. T h e w o r k is still p r e l i m i n a r y , s i n c e w e b e g a n to u s e this a p p r o a c h o n l y 3 y e a r s ago. C o n s e q u e n t l y the n u m b e r o f cases is s m a l l . O u r a i m i n this p a p e r is to e x p l a i n t h e p l a n a n d to d e s c r i b e t h e t e c h n i c a l p r o b l e m s so t h a t t h e s e c a n b e k e p t to modest proportions.
Materials and methods There were ten patients, four boys and six girls, in our series with an average age of 13.5 years (range 9 to 15 years); eight had osteosarcomas and two Ewing's sarcomas. The sites were the distal femur in seven the proximal tibia in two and the proximal humerus in one. The grading of the osteosarcomas according to Enneking's classification was II B1 in 2, II B2 in 5, and II B3 in 1 case.
Treatment protocol Operation was carried out after biopsy and then chemotherapy for 2 or 3 months. The specimen was analysed by Huven and Rosen's method which allowed the patients to be divided into good or bad responders to chemotherapy, which is the essential prognostic criterion [9, 11]. Neoadjuvant chemotherapy was given according to the Rosen TI0 protocol, high dose methotrexate (8-10 g/m 2) for 7 courses and adriamycin for 2 courses before operation. Resection with reconstruction was done only in good responders, as judged by clinical, scintigraphic and sometimes angiographic criteria [2]. This was possible in about 70% of of our cases and these form the group in the present study. Amputation was used for the bad responders or if technical conditions required it. After operation, the chemotherapy regime was continued in good responders, but in bad responders cisplatin was also given. The treatment lasted for l0 months after diagnosis. Grafts with ligaments and tendons were taken from donors under 40 years of age under sterile conditions less than 6 h after death. Donors were tested for hepatitis, AIDS and syphilis; routine bacteriological cultures were taken and repeated at the time of implantation [6, 10]. Conservation of the grafts was by deep freezing ( - 8 0 ° C) according to the Gross protocol. None of the grafts was irradiated [12].
250
R. Kohler et al.: Massive bone allografts in children f
3
4
2
Operative procedures The surgical plan was based on information from magnetic resonance imaging which was valuable for deciding section levels. CT scanning was used to determine, for example,
1
Fig. 1. The different types of allograft which have been used in this series of children
whether the fibula should be kept or not. Bone scintigraphy, and sometimes angiography, were also carried out. The accepted principles of tumour surgery were followed keeping away from the tumour, removing adjacent soft tissues and resecting a wide margin of bone [5]. We have practised two types of resection (Fig. 1) and reconstruction using wide margins with an intercalary autograft in three cases, and major transarticular resection with a terminal osteoarticular allograft in seven. Osteosynthesis was by plates (Fig. 2) at first and later by locked intramedullary rods which give better results. Reconstruction of knee ligaments was as complete as possible whether or not the patient's own ligaments were available and depended on the level of resection. Autogenous cancellous bone was packed around the graft-host junction. In the intercalary grafts the vascularised fibula was screwed beside the graft a few months later (Fig. 3). In children whose bone age was under 13 years, an epiphyseodesis at the opposite knee was carried out in order to stop growth when the predicted difference in length was 3 cm or more.
Postoperative management Continuous passive motion for the knee was used immediately after operation. A plaster cast was then applied for 3 months, after which the knee ligaments were protected by a light brace (Fig. 4); at this stage, knee movement was between 0 and 90 °. Partial weight bearing was possible in a long leg brace and full weight bearing allowed 12 months after operation.
Results Ten cases have been followed up for a mean of 22 m o n t h s ( r a n g e 7 t o 38 m o n t h s ) . No patient died; none developed a recurrence or metastases. Chemotherapy was completed in all w i t h g o o d r e s u l t s . T h e r e w e r e 8 g o o d r e s p o n d ers a n d 2 b a d r e s p o n d e r s .
Functional results Fig. 2. a Osteosarcoma of the distal femur in a 14 year old boy; b The graft is shown 3 years after operation; c The knee joint at this time
The range of knee movement was quickly restored to normal in patients with intercalary grafts. With osteoarticular grafts, the range of movement was o n a v e r a g e 90 ° ( r a n g e 30 ° t o 120°). I n s t a b i l i t y
R. Kohler et al.: Massive bone allografts in children
251
Fig. 3. An intercalary graft supplemented by a vascularised fibular autograft
Fig. 5 a Osteosarcoma of the tibia of a 13 year old girl; b Treatment by an allograft and a locked intramedullary nail Fig. 4. The "Variesta" type of brace used to protect the knee ligaments, particularly against valgus/varus strains was present in half the cases, with mainly valgusvarus laxity and very little a n t e r o p o s t e r i o r laxity. Patients who have been followed for m o r e t h a n 18 m o n t h s have no difficulty in walking with a light brace. T h e y do not have pain and feel quite stable. The difference in length in the lower limbs was on average 2 cm. An epiphyseodesis o f the opposite knee was d o n e in two cases.
A suitable fit could not be o b t a i n e d with the osteoarticular graft in five cases, but no u n t o w a r d c o n s e q u e n c e followed. H o w e v e r , we are doubtful a b o u t the functional future o f the articular cartilage in the graft and the future o f the opposing cartilage. C o n s o l i d a t i o n o c c u r r e d in the outer part o f the bone, but we are also u n c e r t a i n c o n c e r n i n g deep consolidation. It seems that after 18 m o n t h s there is true end to end consolidation.
Anatomical results T h e r e were no p r o b l e m s with the intercalary grafts; in particular the vascularised fibula gave g o o d biological a n d m e c h a n i c a l results in 3 cases.
Complications Palsy o f the deep p e r o n e a l nerve, which recovered, o c c u r r e d in 2 cases o f fibular resection.
252
R. Kohler et al.: Massive bone allografts in children
Fig. 6 a - d . Bone healing at the graft-host junction, a immediately after operation; b at 4 months; c at 16 months; d at 24 months
There was one deep infection of the proximal tibia which occurred 6 months after operation and was due to the brace rubbing. Treatment was medical, but there are now signs of chronic osteomyelitis which does not affect his daily life; we are uncertain about the future of this graft. One superficial infection in a graft of the proximal humerus developed a small abscess which dried up after 2 months. The plates failed in two cases without any effect on the bone. Both were treated by a locked intramedullary nail which we now prefer for primary treatment. Fracture of two grafts occurred at 10 and 18 months, and were linked to recognised fragility of the graft. This complication was favoured by imperfect osteosynthesis and raised the question of whether it is better to change the graft as we did or to replace it with an endoprosthesis. Children accept psychologically the postoperative management, but are upset by the complications. Discussion
The choice between resection and reconstruction or amputation is easily decided by a team of oncologists, radiologists and surgeons. The choice between an allograft or an endoprosthesis is more difficult. A prosthesis might seem preferable because function is quickly restored, little follow up is necessary and the patient is more comfortable [4, 5]. These immediate advantages can be outweighed by a number predictable drawbacks such as mechanical problems at the interface and the difficulties of any secondary operations. An allo-
graft presents a more biological approach. A shorter resection makes it possible to save the growth plate if the joint is not affected, and an arthrodesis or prosthesis can always be considered after growth has stopped should degeneration of the articular cartilage occur [1, 3, 14]. The two methods are not necessarily incompatible since they are performed together on occasions [14]. Our short experience has led us to appreciate the importance of meticulous surgical technique and the value of having two skilled surgeons, one in charge of the resection, the other dealing with the graft. The best possible fit of the graft (Fig. 5), the use of locked nails and autogenous cancellous graft are required. The practical problems of a bone bank having little stock are compounded in children by the size requirement. This is assessed by radiographs, and bone preferably taken from females. A slight mismatch at the junction can improve in time because of the adaptability of children's bones during growth. It is difficult to assess healing at the host-graft junction (Fig. 6), but this is sometimes made possible by biopsy. The graft is always very fragile for the first 12 to 18 months and the limb must be protected although such problems are less in the upper limb [8]. It seems premature to make a final choice of treatment at present, but the complications we have had are not serious enough to prevent us continuing to use this method. Pitfalls in the first 18 months are more numerous with an allograft than a prosthesis, but we think that ultimately the advantages of the allograft will prevail. Osteoarthritis or instability can be more easily treated
R. Kohler et al.: Massive bone allografts in children
when they occur in an adult than a broken endoprosthesis. It will only be possible to make a correct decision about which is the best method when a series of allografts is compared with an identical series of prostheses, both of which have been followed up for at least 5 years. References 1. Aebi M, Regazzoni P (1988) Bone transplantation. Springer, Berlin Heidelberg New York 2. Brunat-Mentigny M, Blondet R, Bouffet E, Chauvot P, Moyen B, Philip T (1984) Chimioth6rapie premi6re et chirurgie conservatrice dans le traitement actuel de l'ost6osarcome. A propos de vingt-quatre malades. Ann P6diatr 31:773-778 3. Czitrom AA, Langer F, McKee N, Gross AE (1986) Bone and cartilage allotransplantation. A review of 14 years of research and clinical studies. Clin Orthop 208: 141-145 4. Dubousset J, Kalifa C, Mlika N (1986) Traitement actuel du sarcome ost6og6ne. Cahiers d'Enseignement Sofcot, Conf6rences SOFCOT. L'Expansion, Paris, pp 279-303 5. Dubousset J, Missenard G, Genin J (1985) Traitement chirurgical conservateur des sarcomes ost6og6niques des membres. Techniques et r6sultats fonctionnels. Rev Chir Orthop, pp 435-450 6. Friedlaender GE (1982) Current concepts review bonebanking. J Bone Joint Surg [Am] 64:307-311
253 7. Genton N, Carlioz H (1985) Les ost6osarcomes des membres chez l'enfant. Chir P6diatr 26:201-260 8. Gerard Y (1988) Banque d'os (allogreffes). Rev Chir Orthop 74:109-159 9. Huvos AG, Rosen G, Marcove RC (1977) Primary osteogenic sarcoma, pathologic aspects in 20 patients after treatment with chemotherapy in bloc resection and prosthetic bone replacement. Arch Pathol Lab Med 101: 14-18 10. Poitout D (1985) Conservation et utilisation de l'os de banque. Cahiers d'Enseignements de la SOFCOT, pp 157-177 11. Rosen G, Caparros B, Huvos AG, Kosloff C, Nirenberg A, Cacavio A, Marcove RC, Lane JM, Urban C (1982) Peroperative chemotherapy for osteogenic sarcoma: selection of postoperative adjuvant chemotherapy based on the response of the primary tumor to preoperative chemotherapy. Cancer, 49:1221-1230 12. Roussouly P, Mine C, Petretto E, Gonon G, Fischer LP (1988) Effet de l'irradiation par rayonnement gamma sur la r6sistance m6canique d'os longs irradi6s par rayon gamma. Rev Chir Orthop 74 (Suppl II): 199 13. Springfield DS, Schmidt R, Graham-Pole J, Marcus RB, Spanier SS, Enneking WF (1988) Surgical treatment for osteosarcoma. J Bone Joint Surg [Am] 70:1124-1130 14. Tomeno B, Courpied JP, Loty B (1988) Techniques et indications des greffes et transplantations osseuses et ost6ocartilagineuses. Encycl Med Chir Techniques Chirurgicales Orthop6diques, Paris 44030 (II): 16
International Orthopaedics (SlCOY) (1990) 14:249-253
Orthopaedics © Springer-Verlag 1990
Massive bone allografts in children R. Kohler 1, F. Lorge 1, M. Brunat-Mentigny 2, D. Noyer 3, and L. PatricoP JClinique Mutualiste, 107, rue Trarieux, F-69003 Lyon, France 2Centre Anticancereux Leon Berard, 28, rue La~nnec, F-69008 Lyon, France 3Laboratoire Anatomo-pathologique, H6pital Croix-Rousse, F-69004 Lyon, France
S u m m a r y . A group o f ten children and adolescents
with malignant bone tumours (eight osteosarcomas, two Ewing's tumours) were treated with chemotherapy and resection with allograft reconstruction. Intercalary grafts were used in three cases and terminal osteoartieular grafts at the knee in seven. The mean follow up was 22 months. Functional results were satisfactory, but there were some complications related to the graft. Although these are early results, we believe that the method is justified and is preferable to the use o f an endoprosthesis, particularly in children. R~sum~. Un groupe de dix enfants et adolescents
atteints de tumeurs osseuses malignes (huit ostdosarcomes, deux sarcomes d'Ewing) ont dtd traitds par chimiothbrapie et rbsection suivies d'une reconstruction par allogreffes. Des greffes intercalaires ont dtd utilisdes dans trois cas et des greffes terminales ostko-articulaires au niveau du genou dans sept cas. Le recul moyen est de 22 tools. Les rbsultats fonctionnels ont dtd satisfaisants, mais on a observb quelques complications en relation avec la greffe. Bien qu'il ne s'agisse ld que de rdsultats prbcoces, nous pensons que cette mdthode est justifide et qu'elle est prbf&able d l'utilisation d'endoprothOses, surtout chez les enfants.
Introduction W e r e p o r t o u r e x p e r i e n c e o f l i m b s a l v a g e b y res e c t i o n a n d a l l o g r a f t r e c o n s t r u c t i o n i n t e n child r e n a n d a d o l e s c e n t s w i t h m a l i g n a n t b o n e tum o u r s . T h i s d e v e l o p m e n t is d u e to the s p e c t a c u l a r
Offprint requests to: R. Kohler
p r o g r e s s i n c h e m o t h e r a p y o v e r t h e p a s t few y e a r s [4, 7, 13]. T h e w o r k is still p r e l i m i n a r y , s i n c e w e b e g a n to u s e this a p p r o a c h o n l y 3 y e a r s ago. C o n s e q u e n t l y the n u m b e r o f cases is s m a l l . O u r a i m i n this p a p e r is to e x p l a i n t h e p l a n a n d to d e s c r i b e t h e t e c h n i c a l p r o b l e m s so t h a t t h e s e c a n b e k e p t to modest proportions.
Materials and methods There were ten patients, four boys and six girls, in our series with an average age of 13.5 years (range 9 to 15 years); eight had osteosarcomas and two Ewing's sarcomas. The sites were the distal femur in seven the proximal tibia in two and the proximal humerus in one. The grading of the osteosarcomas according to Enneking's classification was II B1 in 2, II B2 in 5, and II B3 in 1 case.
Treatment protocol Operation was carried out after biopsy and then chemotherapy for 2 or 3 months. The specimen was analysed by Huven and Rosen's method which allowed the patients to be divided into good or bad responders to chemotherapy, which is the essential prognostic criterion [9, 11]. Neoadjuvant chemotherapy was given according to the Rosen TI0 protocol, high dose methotrexate (8-10 g/m 2) for 7 courses and adriamycin for 2 courses before operation. Resection with reconstruction was done only in good responders, as judged by clinical, scintigraphic and sometimes angiographic criteria [2]. This was possible in about 70% of of our cases and these form the group in the present study. Amputation was used for the bad responders or if technical conditions required it. After operation, the chemotherapy regime was continued in good responders, but in bad responders cisplatin was also given. The treatment lasted for l0 months after diagnosis. Grafts with ligaments and tendons were taken from donors under 40 years of age under sterile conditions less than 6 h after death. Donors were tested for hepatitis, AIDS and syphilis; routine bacteriological cultures were taken and repeated at the time of implantation [6, 10]. Conservation of the grafts was by deep freezing ( - 8 0 ° C) according to the Gross protocol. None of the grafts was irradiated [12].
250
R. Kohler et al.: Massive bone allografts in children f
3
4
2
Operative procedures The surgical plan was based on information from magnetic resonance imaging which was valuable for deciding section levels. CT scanning was used to determine, for example,
1
Fig. 1. The different types of allograft which have been used in this series of children
whether the fibula should be kept or not. Bone scintigraphy, and sometimes angiography, were also carried out. The accepted principles of tumour surgery were followed keeping away from the tumour, removing adjacent soft tissues and resecting a wide margin of bone [5]. We have practised two types of resection (Fig. 1) and reconstruction using wide margins with an intercalary autograft in three cases, and major transarticular resection with a terminal osteoarticular allograft in seven. Osteosynthesis was by plates (Fig. 2) at first and later by locked intramedullary rods which give better results. Reconstruction of knee ligaments was as complete as possible whether or not the patient's own ligaments were available and depended on the level of resection. Autogenous cancellous bone was packed around the graft-host junction. In the intercalary grafts the vascularised fibula was screwed beside the graft a few months later (Fig. 3). In children whose bone age was under 13 years, an epiphyseodesis at the opposite knee was carried out in order to stop growth when the predicted difference in length was 3 cm or more.
Postoperative management Continuous passive motion for the knee was used immediately after operation. A plaster cast was then applied for 3 months, after which the knee ligaments were protected by a light brace (Fig. 4); at this stage, knee movement was between 0 and 90 °. Partial weight bearing was possible in a long leg brace and full weight bearing allowed 12 months after operation.
Results Ten cases have been followed up for a mean of 22 m o n t h s ( r a n g e 7 t o 38 m o n t h s ) . No patient died; none developed a recurrence or metastases. Chemotherapy was completed in all w i t h g o o d r e s u l t s . T h e r e w e r e 8 g o o d r e s p o n d ers a n d 2 b a d r e s p o n d e r s .
Functional results Fig. 2. a Osteosarcoma of the distal femur in a 14 year old boy; b The graft is shown 3 years after operation; c The knee joint at this time
The range of knee movement was quickly restored to normal in patients with intercalary grafts. With osteoarticular grafts, the range of movement was o n a v e r a g e 90 ° ( r a n g e 30 ° t o 120°). I n s t a b i l i t y
R. Kohler et al.: Massive bone allografts in children
251
Fig. 3. An intercalary graft supplemented by a vascularised fibular autograft
Fig. 5 a Osteosarcoma of the tibia of a 13 year old girl; b Treatment by an allograft and a locked intramedullary nail Fig. 4. The "Variesta" type of brace used to protect the knee ligaments, particularly against valgus/varus strains was present in half the cases, with mainly valgusvarus laxity and very little a n t e r o p o s t e r i o r laxity. Patients who have been followed for m o r e t h a n 18 m o n t h s have no difficulty in walking with a light brace. T h e y do not have pain and feel quite stable. The difference in length in the lower limbs was on average 2 cm. An epiphyseodesis o f the opposite knee was d o n e in two cases.
A suitable fit could not be o b t a i n e d with the osteoarticular graft in five cases, but no u n t o w a r d c o n s e q u e n c e followed. H o w e v e r , we are doubtful a b o u t the functional future o f the articular cartilage in the graft and the future o f the opposing cartilage. C o n s o l i d a t i o n o c c u r r e d in the outer part o f the bone, but we are also u n c e r t a i n c o n c e r n i n g deep consolidation. It seems that after 18 m o n t h s there is true end to end consolidation.
Anatomical results T h e r e were no p r o b l e m s with the intercalary grafts; in particular the vascularised fibula gave g o o d biological a n d m e c h a n i c a l results in 3 cases.
Complications Palsy o f the deep p e r o n e a l nerve, which recovered, o c c u r r e d in 2 cases o f fibular resection.
252
R. Kohler et al.: Massive bone allografts in children
Fig. 6 a - d . Bone healing at the graft-host junction, a immediately after operation; b at 4 months; c at 16 months; d at 24 months
There was one deep infection of the proximal tibia which occurred 6 months after operation and was due to the brace rubbing. Treatment was medical, but there are now signs of chronic osteomyelitis which does not affect his daily life; we are uncertain about the future of this graft. One superficial infection in a graft of the proximal humerus developed a small abscess which dried up after 2 months. The plates failed in two cases without any effect on the bone. Both were treated by a locked intramedullary nail which we now prefer for primary treatment. Fracture of two grafts occurred at 10 and 18 months, and were linked to recognised fragility of the graft. This complication was favoured by imperfect osteosynthesis and raised the question of whether it is better to change the graft as we did or to replace it with an endoprosthesis. Children accept psychologically the postoperative management, but are upset by the complications. Discussion
The choice between resection and reconstruction or amputation is easily decided by a team of oncologists, radiologists and surgeons. The choice between an allograft or an endoprosthesis is more difficult. A prosthesis might seem preferable because function is quickly restored, little follow up is necessary and the patient is more comfortable [4, 5]. These immediate advantages can be outweighed by a number predictable drawbacks such as mechanical problems at the interface and the difficulties of any secondary operations. An allo-
graft presents a more biological approach. A shorter resection makes it possible to save the growth plate if the joint is not affected, and an arthrodesis or prosthesis can always be considered after growth has stopped should degeneration of the articular cartilage occur [1, 3, 14]. The two methods are not necessarily incompatible since they are performed together on occasions [14]. Our short experience has led us to appreciate the importance of meticulous surgical technique and the value of having two skilled surgeons, one in charge of the resection, the other dealing with the graft. The best possible fit of the graft (Fig. 5), the use of locked nails and autogenous cancellous graft are required. The practical problems of a bone bank having little stock are compounded in children by the size requirement. This is assessed by radiographs, and bone preferably taken from females. A slight mismatch at the junction can improve in time because of the adaptability of children's bones during growth. It is difficult to assess healing at the host-graft junction (Fig. 6), but this is sometimes made possible by biopsy. The graft is always very fragile for the first 12 to 18 months and the limb must be protected although such problems are less in the upper limb [8]. It seems premature to make a final choice of treatment at present, but the complications we have had are not serious enough to prevent us continuing to use this method. Pitfalls in the first 18 months are more numerous with an allograft than a prosthesis, but we think that ultimately the advantages of the allograft will prevail. Osteoarthritis or instability can be more easily treated
R. Kohler et al.: Massive bone allografts in children
when they occur in an adult than a broken endoprosthesis. It will only be possible to make a correct decision about which is the best method when a series of allografts is compared with an identical series of prostheses, both of which have been followed up for at least 5 years. References 1. Aebi M, Regazzoni P (1988) Bone transplantation. Springer, Berlin Heidelberg New York 2. Brunat-Mentigny M, Blondet R, Bouffet E, Chauvot P, Moyen B, Philip T (1984) Chimioth6rapie premi6re et chirurgie conservatrice dans le traitement actuel de l'ost6osarcome. A propos de vingt-quatre malades. Ann P6diatr 31:773-778 3. Czitrom AA, Langer F, McKee N, Gross AE (1986) Bone and cartilage allotransplantation. A review of 14 years of research and clinical studies. Clin Orthop 208: 141-145 4. Dubousset J, Kalifa C, Mlika N (1986) Traitement actuel du sarcome ost6og6ne. Cahiers d'Enseignement Sofcot, Conf6rences SOFCOT. L'Expansion, Paris, pp 279-303 5. Dubousset J, Missenard G, Genin J (1985) Traitement chirurgical conservateur des sarcomes ost6og6niques des membres. Techniques et r6sultats fonctionnels. Rev Chir Orthop, pp 435-450 6. Friedlaender GE (1982) Current concepts review bonebanking. J Bone Joint Surg [Am] 64:307-311
253 7. Genton N, Carlioz H (1985) Les ost6osarcomes des membres chez l'enfant. Chir P6diatr 26:201-260 8. Gerard Y (1988) Banque d'os (allogreffes). Rev Chir Orthop 74:109-159 9. Huvos AG, Rosen G, Marcove RC (1977) Primary osteogenic sarcoma, pathologic aspects in 20 patients after treatment with chemotherapy in bloc resection and prosthetic bone replacement. Arch Pathol Lab Med 101: 14-18 10. Poitout D (1985) Conservation et utilisation de l'os de banque. Cahiers d'Enseignements de la SOFCOT, pp 157-177 11. Rosen G, Caparros B, Huvos AG, Kosloff C, Nirenberg A, Cacavio A, Marcove RC, Lane JM, Urban C (1982) Peroperative chemotherapy for osteogenic sarcoma: selection of postoperative adjuvant chemotherapy based on the response of the primary tumor to preoperative chemotherapy. Cancer, 49:1221-1230 12. Roussouly P, Mine C, Petretto E, Gonon G, Fischer LP (1988) Effet de l'irradiation par rayonnement gamma sur la r6sistance m6canique d'os longs irradi6s par rayon gamma. Rev Chir Orthop 74 (Suppl II): 199 13. Springfield DS, Schmidt R, Graham-Pole J, Marcus RB, Spanier SS, Enneking WF (1988) Surgical treatment for osteosarcoma. J Bone Joint Surg [Am] 70:1124-1130 14. Tomeno B, Courpied JP, Loty B (1988) Techniques et indications des greffes et transplantations osseuses et ost6ocartilagineuses. Encycl Med Chir Techniques Chirurgicales Orthop6diques, Paris 44030 (II): 16
