Surgical Outcomes of Pediatric Osteosarcoma Patients Treated With a Failed Allograft Reconstruction Revised to an Endoprosthesis.
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BACKGROUND: Allograft reconstructions offer unique benefits as a limb salvage option for pediatric osteosarcoma; however, failures are common and may require revision to an endoprosthesis. Currently, no study has analyzed outcomes following conversion from a failed allograft reconstruction to endoprosthesis in this population. The purpose of this study is to identify the outcomes of patients with pediatric osteosarcoma about the knee treated with an allograft later revised to an endoprosthesis and, secondarily, perform an exploratory comparison to similar patients treated primarily with an endoprosthesis. METHODS: We conducted a retrospective cohort study of pediatric patients with osteosarcoma of the distal femur or proximal tibia who underwent limb salvage between 1990 and 2024. The study cohort included patients initially treated with an allograft revised to an endoprosthesis. The comparison cohort included patients treated primarily with endoprostheses. Demographics, surgical outcomes, complications, Musculoskeletal Tumor Society (MSTS) scores, and functional range of motion (ROM) were collected and analyzed. RESULTS: Thirteen patients underwent revision from allograft to endoprosthesis and were compared to 48 patients treated primarily with endoprostheses. There were no significant differences in primary disease characteristics between the 2 cohorts. The outcomes from conversion to endoprosthesis were comparable to the primary endoprosthesis group with no significant differences in complication rates, MSTS scores, ROM, or revision rates between cohorts. Endoprosthesis survival at 5, 10, and 15 years in the allograft revision cohort was 92.3%, 76.9%, and 51.3%, respectively. On exploratory analysis, there was a significantly higher endoprosthesis implant survival in the allograft revision cohort (P = .02); however, this finding attenuated after exclusion of expandable implants from the primary endoprosthesis cohort (P = .21). CONCLUSIONS: Revising pediatric osteosarcoma patients to endoprostheses following an initial biologic reconstruction presents a complex but viable option associated with a significant complication rate. Despite these challenges, most patients achieved satisfactory functional outcomes comparable to patients with primary endoprosthesis reconstructions in this exploratory analysis. These findings support allograft use as a viable initial option in select patients, offering the benefit of potential bone stock preservation and delayed endoprosthesis implantation without clear compromise of long-term outcomes. KEY CONCEPTS: (1)This study foound satisfactory patient-reported, functional, and surgical outcomes in patients revised from an allograft to an endoprosthesis.(2)We identified improved implant survival after revision to an endoprosthesis compared to prior studies.(3)Allograft revision patients had comparable outcomes to patients with primary endoprosthetic reconstructions. LEVEL OF EVIDENCE: III.