Bone Transplantation in Limb Saving Surgeries: The Philippine Experience

Abstract

Until the turn of the decade, Filipino patients afflicted with malignant and aggressive extremity tumors were almost uniformly treated with mutilating amputations. Limb-saving surgery only recently became an option locally — this resulting not only from a better comprehension of surgical oncologic principles but also from the development and refinement of reconstructive procedures following such surgeries. Foremost among the latter is the use of long bone transplants, otherwise known as large segment bone allografts. Large-segment allografts are available from the Tissue and Bone Bank of the University of the Philippines — the only bank of its kind in the country. All allografts are harvested from appropriate donors (both cadaveric and live), processed at the Bank, radiation-sterilized at the Philippine Nuclear Research Institute (PNRI), and finally brought back to and stored in a -80°C deep freezer at the Bank.

This paper presents our 4-year experience with large-segment allografts for extensive defects of limb salvage surgery in musculoskeletal tumors. All patients included in this presentation had: (1) malignant or aggressive extremity tumors; (2) surgery performed by the University of the Philippines-Musculoskeletal Tumor Unit (UP-MuST Unit); (3) follow-up of at least one year; and (4) available pre- and post-operative radiographs for review. Over a period of 4 years (January 1993-January 1997), 63 patients with malignant or aggressive extremity tumors (who formerly would have been amputated) underwent limb salvage surgery by the UP-MuST Unit. Twenty (21) of these patients had reconstructions utilizing irradiated large-segment allografts and fulfilled the above criteria for inclusion in this review.

Tumors included osteosarcoma (6), giant cell tumors (12), and metastatic lesions (3). Ages ranged from 16-64 years; 14 males and 7 females. Bones involved were the femur (12), tibia (6), and humerus (3). Average length of the defects was 15 cm. Surgeries performed were segmental replacement (5), resection arthrodesis (12), hemicondylar allograft (3), and allograft-prosthesis-composite (1). Implants used were usually intramedullary nails or plates and screws, with or without bone cement. Follow-up ranged from 16-60 months or until death. Sixteen (16) were alive with NED (no evidence of disease), 3 were dead (2 of disease, 1 of other causes), and 2 were AWED (alive with evidence of disease). Functional evaluation using the criteria of the International Society of Limb Salvage (ISOLS) was performed in 18 patients. There were 15 good to excellent results (83%) – many having returned to their previous work and recreation. The 3 poor results were due to infections in 2 cases, and a fracture (secondary to a fall) in 1 case.

Limb-saving surgery for Filipino patients with musculoskeletal tumors continues to be a challenge because of both tumor size and the size of the defect requiring reconstruction. Large-segment allografts from the UP-Tissue & Bone Bank, however, make this difficult surgery realizable in our setting; and offers to our patients a chance to save not only life but also limb.

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