Strategies for Pediatric Diaphyseal Bone Reconstruction of the Lower Limb After Oncologic Resection: A Multicenter Retrospective Analysis.
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BACKGROUND: Reconstruction of diaphyseal bone defects of the lower limb after oncologic resection in children remains a major challenge. Several biological techniques are used, including the induced membrane technique (IMT), vascularized fibular graft (VFG), and combined allograft with vascularized fibula graft (CAVFG), but comparative data in pediatric populations remain limited. QUESTIONS/PURPOSES: We asked: (1) What are the consolidation outcomes after biological reconstruction of pediatric lower-limb diaphyseal defects? (2) Which factors are associated with time to bone union? (3) What are the complication and revision profiles of these reconstruction strategies? METHODS: We conducted a national multicenter retrospective study including pediatric patients (<18 years) who underwent diaphyseal resection of the femur or tibia for malignant bone tumors or adamantinoma between 2004 and 2024. Patients were reconstructed using IMT, VFG, or CAVFG. The primary endpoint was radiographic consolidation at 1 year. Secondary outcomes included overall union rate, time to union, complications, and revision surgery. Time-to-event analyses were performed using Kaplan-Meier and Cox regression models. RESULTS: A total of 133 patients were included (IMT 69, VFG 22, CAVFG 42). Overall bone union was achieved in 72.9% of patients, with no significant difference between reconstruction techniques (IMT 75.4%, VFG 81.8%, CAVFG 64.3%; p = 0.272). Consolidation at 1 year, estimated by Kaplan-Meier analysis, occurred in 35.2% of cases. Median time to union was 18 months and did not differ significantly between techniques. Tibial localization was independently associated with higher union rates (OR 3.90, 95% CI 1.19-12.8; p = 0.024) and shorter time to union (HR 1.89, 95% CI 1.06-3.38; p = 0.032). Complications occurred in 64.1% of patients and 57% required revision surgery, without differences between techniques. CONCLUSION: Biological reconstruction of pediatric lower-limb diaphyseal defects allows limb salvage with acceptable union rates but prolonged healing and high complication rates. No technique demonstrated clear superiority, supporting an individualized reconstruction strategy based primarily on anatomical and mechanical considerations.