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Dr. Ernest Conrad Discusses Pediatric Limb-Salvage Surgery
Dr. Conrad is the Tissue Services's medical director.
Dr. Conrad is the director of the Pediatric Bone Tumor Clinic at Children's Hospital and Regional Medical Center and Professor and interim director of the Orthopaedics and Sports Medicine Department at the University of Washington Medical Center. He is also the Tissue Services's medical director.
An amputation was once the “gold standard” for a patient with a malignancy or a serious osseous defect of the lower extremity from any cause. While a patient can still recover from an amputation and be functional, successful limb-salvage surgery offers obvious benefits.
Tumors involving the skeleton may be reconstructed in one of three ways: with a cadaveric bony transplant, an autograft from the patient's own bone, or a metallic or synthetic implant. When a tumor involves a large bony segment, an autologous bone graft from the patient is not possible, given the size of the autograft that would be necessary to reconstruct the limb. These reconstructions basically involve metallic implants for joints and osseous cadaveric allografts for shaft resections. While both techniques are valuable and beneficial for the patient, allografts represent the best reconstruction, because complex joint reconstruction is avoided, and the graft has the ability to heal the site involved.
“The courage of parents who consent to donation when their child dies is nothing short of heroic.” – Dr. Chappie Conrad
One key to successful allograft reconstruction is the quality of the graft itself. It must be recovered from a relatively young donor whose bones have a lower risk of fracture and be procured and by certified technicians. The utmost care must be taken to assure the suitability of the donor and to prevent bacterial contamination, so the allograft the patient receives is safe.
Cassandra Burris' case is an excellent example of the value of bone tumor resection and reconstruction with a large bony shaft. Cassandra faces the additional major challenge of growth continuation in a young child. At the age of eight, Cassandra had half her skeletal growth remaining, a factor we needed to compensate for.
Dr. Conrad explains surgical lengthening.
Gross growth discrepancies can be successfully addressed with surgical lengthenings if planned in a prospective fashion. They do call for additional operations; in a very young child, as many as three to four subsequent surgeries may be required but can be done reliably even in young patients, as in Cassandra's case. The subsequent procedures are relatively minor compared to the original tumor resection and reconstruction.
The complications of reconstructions with large osseous shaft transplants include delayed union between the host and the donor bone, fractures, infections, and problems connected with reconstructing growth. We avoid joint complications, which over the lifetime of the patient are a major source of morbidity and disability, when we do large shaft reconstructions.
Avoiding that source of problems is a major accomplishment. The overall success rate for a large osseous shaft graft is approximately 75 percent. Three-fourths of the patients heal their graft within 12 to14 months of transplantation. The biggest challenge for the patient is the lengthy time waiting for bony union, which requires approximately 12 to 18 months for a full recovery.
After a full recovery (as demonstrated by radiographic studies), the patient is seen once each year by the orthopaedic surgeon. Young children have continued growth measurements to assess the length of the involved limb and to make minor adjustments.
Patients who receive these grafts are also frequently undergoing chemotherapy. The orthopaedic surgery is a minor event compared to the chemotherapy. This type of surgery does not interfere with the patient's chemotherapy in the overwhelming percentage of cases, and it enables the patient to keep a functional limb rather than suffer an amputation, on top of the anxiety caused by tumor issues and chemotherapy.
Young children and teenagers have major expectations in the field of recreational activities and sports. Their “life's work” is to play. Unfortunately, having a major surgical reconstruction following tumor resection does limit some of the sports in which these children can participate.
However, a child with a well-healed allograft can participate in non-contact sports. Most of these patients return to some type of sporting activity after a successful recovery, and in many respects, can return to normal, active lives.