Since 1976, the authors have performed a total of 36 resections of malignant tumors of the limbs with reconstruction of these by implantation of allografts. All allografts have been supplied by the University of Miami Tissue Bank. Following resection of the long-bone tumor and obtaining acceptable margins, the allograft was inserted to the limb defect with three different techniques: (1) in addition to a custom prosthess as a hemi-joint reconstruction, i.e., a custom Neer prosthesis and proximal humerus allograft; (2) an osteoarticular graft to replace an articular surface resected with the metaphyseal-diaphyseal portion of the tumor; and (3) an intercalary diaphyseal-metaphyseal graft replacing the resected tumor by preserving the recipient articular surface. Of the 36 tumors, one was in Stage III disease. The remainder were Stage II A or B by the System of Enneking. All of these patients had adjuvant chemotherapy. The follow-up time was 24 months to 96 months. The resection of tumors in 36 patients and treatment with postoperative chemotherapy resulted in a mortality of eight out of 36 and one amputation due to recurrence. Satisfactory results were obtained in 19 of 36 patients. If the tumor failures (eight deaths) and the amputation are subtracted from this number, the success rate is 70% (19/27). Intercalary grafts were more successful than osteoarticular grafts. Chemotherapy was started one to two weeks postoperation for all but four patients to whom it was also given preoperation. These patients were in a Children's Cancer Study Group (CCSG) protocol for prospective study of the effects of preoperative chemotherapy. There was no apparent difference in the allograft success in these patients as compared to patients receiving only postoperative chemotherapy. The drugs used were Adriamycin, high-dose methotrexate, Cytoxan, vincristine, and bleomycin. Complications were expectedly high (16/27) 51%. These included skin necrosis, wound infections, allograft resorption, allograft fracture, and nonunion. The presence of nonunion did not appear to affect the final end result, especially in the intercalary grafts. This study does not reveal the degree to which chemotherapy protocol directly affected the grafts' integration in this very high-risk patient category. The disease process itself suggests that the risk/benefit ratio of this procedure requires careful selection of the patient with Stage II B tumors. However, it is clear that the success is not interdepent upon the use of chemotherapy alone but is a multifactorial consequence of graft fixation, age (and morbidity) of patient, size of the graft, and the natural history of high-grade tumors.
ASJC Scopus subject areas
- Orthopedics and Sports Medicine