1. 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 Eralp
Istanbul University
Istanbul Faculty of Medicine
Department of Orthopsedics and Traumatology

2. ? Recycled bone + Amputation ? Rotationplasty ? Megaprosthesis ?
Biological reconstruction ?
Massive allograft
Recycled bone:
Autoclaving
Irradiation
Pasteurization
Cryopreservation
FVFG
Composites
Massive allograft +
Recycled bone + ?
There 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.

3. Massive Allograft - alone
Disadvantages
Avascular
Consolidation too late
Expensive
Immune response
Infection
Resorption
Availability
Socioreligious problems
Anatomical incongruency
6 yo male, ES
Proximal 2/3 of femur
10 yrs follow-up
NED
Ewing 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.
Advantages
Early postop. Xray.
Mass. allograft fixed
w/ IM nail
Primary mechanical strength good
+2 yrs
Extracortical bone
bridging but no union
+3 yrs
Antiobiotic rod
due to infection
Allograft
removed
due to infection

4. Free Vascularized Fibular Graft - alone
Advantages
- Easily available
Vascular
Rapid healing
Disadvantages
Primary mechanical
strength insufficient
14 f, ES
FVFG alone!
+ 7 yrs follow-up
NED
Ewing’s sarcoma of the proximal femur.
Vascularised fibula alone.
Rapid healing but sufficient mechanical strength takes 4 years - too long.
4 yrs for full consolidation and full weight bearing – TOO LONG

5. WHY FROZEN HOT DOG?

6. 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 bone
Superiorities of cryopreservation:
mechanical strength comparable to intact bone
easy availability,
less expensive,
perfect anatomical congruence
better osteoinductive and osteoconductive properties.

7. LN + FVFG = bone in the bun…
Technique
1. Tumor resection
2. Harvesting of FVFG
3. Soft tissue stripping
4. Preparation of medullary cavity
5. Preparation of cortical window for
FVFG pedicle
6. Liquid Nitrogen treatment
Nitrogen tank……………………20 min
Room temperature (20°)………15 min
Heated saline solution (30°) min
7. Reimplantation + osteosynthesis
8. Insertion of FVFG inside prepared bone
segment and anastomosis of pedicle
9. Grafting of osteotomy sites
…or ‘hot dog’
soft tissue stripping
The stages of preparation of bone in the bun or hot dog
tumor resection
bone in the bun!
LN treatment

8. Patients and Methods 14 patients, treated between 2005-2009
8 male, 6 female
Mean age: 13.9 yrs (6-31)
Mean follow-up: 17.1 months (6-46)
9 osteosarcoma, 5 Ewing sarcoma
Tumor localization:
- distal femur, 8 pts
- proximal femur, 2 pts
- femur diaphysis: 1 pt,
- proximal tibia: 2 pts
- tibia mid-diaphysis: 1 pt
+ 17 mo.
14 patients
Mean follow-up: 17.1 months
10 yo male, OS
Distal femur
18 mo. follow-up
NED

9. Patients and Methods Recycled bone: cryopreservation for all patients
FVFG:
- 11 patients: contralateral single strut
- 2 patients: bilateral fibula grafts harvested to bridge a defect longer than single fibula
- 1 patient: ipsilateral single strut
Mean bony defect: 17.2 cm ( )
Mean fibular graft length: 18.9 cm (10-28)
Plate: 13 pts; IM nail: 1 pt.
10 m, OS
Proximal 2/3 femur
43 mo.follow-up
NED
+ 5 mo.
+ 27 mo.
+30 mo.
For 2 patients we used bilateral fibula grafts to bridge a defect longer than single fibula

10. Results Complete consolidation: 8 patients
19 female, OS
Distal femur
Complete consolidation: 8 patients
Mean 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 responding
to tx, synchron. multi-met)
- deep infection: 1 pt
(complete healing w/ antib.,
debr. + VAC)
Mean time for consolidation: 13.4 months
Our 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
10 male, ES
Distal femur
Full wt bearing and very good knee ROM at 15 mo. postop

11. Bone in the bun + 2 mo. + 7 mo. + 11 mo. + 19 mo. + 24 mo.
8 yo. ♀, OSG
LN + FVFG
24 mo. follow-up
NED
+ 2 mo.
+ 7 mo.
+ 11 mo.
+ 19 mo.
+ 24 mo.
osteosarcoma of distal femur
Reconstructed with HOTDOG technique.
Plate was broken at 11 months and revision was performed.
Full consolidation at 19 months

12. Bone in the bun + 17 months 14 yo. ♀, ES LN + FVFG 23 mo. follow-up
NED
+ 5 mo
+ 20 mo.
Ewing’s sarcoma of proximal tibia. Another HOTDOG application. Knee functions at 17 months postop. Full consolidation at 20 months postop.
+ 17 months

13. Bone in the bun + 0 mo. + 3 mo. + 13 mo. + 13 mo. 12 yo. ♂, OSG
LN + double FVFG
17 mo. follow-up
DOD
Osteosarcoma of distal ¾ femur. Length of single fibula was not enough so reconstructed with two fibulas.
+ 0 mo.
+ 3 mo.
+ 13 mo.
+ 13 mo.

14. Bone in the bun 11 ♀, ES Healed pathological fx LN + double FVFG
+ 6 mo follow-up
NED
Ewing sarcoma of femur presented with pathological fracture. 28 cm. bone segment was resected.

15. Bone in the bun + 5 mo. R R Bone scan at 3 mo. postop
Two fibular grafts used for reconstruction. Recycled bone had to be osteotomized due to deformity.
Bone scan
at 3 mo. postop
shows good uptake,
FVFGs are alive.

16. Conclusion Cryopreserved recycled bone: - readily available - cheap
- anatomically congruent
- good mechanical strength
BUT
- DEAD bone
- prolonged consolidation time
Cryopreserved recycled bone is strong but dead…

17. Conclusion FVFG: - LIVING bone - rapid union BUT
- poor mechanical strength
Vascularized fibula graft is alive but weak

18. Solution Combination (HOTDOG) - faster consolidation
- greater mechanical strength
Hotdog is strong and alive… thank you for your attention

19. Thank you
for your attention…