Infection in Massive Bone Allografts

We studied a series of 945 patients who received cadaveric allografts implanted for nonpelvic bone or soft tissue tumor lesions since 1971. We specifically were interested in the role of infection in the graft process, and, more specifically its history, frequency, and affect on outcome. Primary infections (not related to reoperations for nonunions or fractures of the graft) occurred in 75 patients (7.9%), and an additional 46 patients had infections related to reoperations, increasing the total number of patients with infections to 121 (12.8%). The highest frequency of infection occurred in patients with soft tissue tumors, radiated sites, Musculoskeletal Tumor Society Stage IIB tumors, or surgeries consisting of an allograft arthrodesis. Most of the infected grafts failed; however, none of the patients died. One patient had hepatitis C develop, and one patient became HIV positive after receiving the virus from a blood transfusion. A comparison with other series of surgically treated patients, including those receiving metallic devices, suggests that the infection rate may be related to the surgery or the graft’s immunologic resistance, rather than the graft. The problem of infection is a major issue for tumor surgeons. Suggestions regarding how to decrease the frequency of this complication are presented. Level of Evidence: Therapeutic study, Level IV (case series-no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

[1]  T. Malinin,et al.  Massive osteoarticular allografts in the reconstruction of extremities following resection of tumors not requiring chemotherapy and radiation. , 1985, Clinical orthopaedics and related research.

[2]  D. Davy.  Biomechanical issues in bone transplantation. , 1999, The Orthopedic clinics of North America.

[3]  K. Brown.  Complications of limb salvage : prevention, management and outcome, 6th international symposium, Montreal, September 8 to 11, 1991 , 1991 .

[4]  E. Chao,et al.  Reconstruction of musculoskeletal defects about the knee for tumor. , 1987, Clinical orthopaedics and related research.

[5]  H. Mankin,et al.  Bone banking. Update on methods and materials. , 1999, The Orthopedic clinics of North America.

[6]  H. Mankin‡.  A computerized system for orthopaedic oncology. , 2002, Clinical orthopaedics and related research.

[7]  H. Abelson,et al.  Osteosarcoma: fifteen years later. , 1985, The New England journal of medicine.

[8]  M. Gebhardt,et al.  Long-Term Followup of Proximal Femoral Allografts , 2002, Clinical orthopaedics and related research.

[9]  T. Malinin,et al.  Massive allograft implantation following radical resection of high-grade tumors requiring adjuvant chemotherapy treatment. , 1985, Clinical orthopaedics and related research.

[10]  H J Mankin,et al.  Long-Term Results of Allograft Replacement in the Management of Bone Tumors , 1996, Clinical orthopaedics and related research.

[11]  W. Enneking,et al.  Current concepts review. The surgical staging of musculoskeletal sarcoma. , 1980, The Journal of bone and joint surgery. American volume.

[12]  E. Chao,et al.  Prosthetic replacement of the proximal humerus. , 1987, Clinical orthopaedics and related research.

[13]  M. Gebhardt,et al.  The use of frozen cadaveric allografts in the management of patients with bone tumors of the extremities. , 1987, The Orthopedic clinics of North America.

[14]  W. Tomford,et al.  Organization, Legal Aspects and Problems of Bone Banking in a Large Orthopedic Center , 1989 .

[15]  H. Heinzl,et al.  Long-Term Followup of Uncemented Tumor Endoprostheses for the Lower Extremity , 2001, Clinical orthopaedics and related research.

[16]  E. Conrad,et al.  Transmission of the hepatitis-C virus by tissue transplantation. , 1995, The Journal of bone and joint surgery. American volume.

[17]  M. Gebhardt,et al.  Allograft Arthrodesis Treatment of Bone Tumors: A Two-Center Study. , 2002, Clinical orthopaedics and related research.

[18]  M. Ferraro,et al.  Frozen musculoskeletal allografts. A study of the clinical incidence and causes of infection associated with their use. , 1990, The Journal of bone and joint surgery. American volume.

[19]  D. Muscolo,et al.  Human Leukocyte Antigen Matching, Radiographic Score, and Histologic Findings in Massive Frozen Bone Allografts , 1996, Clinical orthopaedics and related research.

[20]  M. Gebhardt,et al.  Complications of Irradiated Allografts in Orthopaedic Tumor Surgery , 2000, Clinical orthopaedics and related research.

[21]  C. H. Herndon,et al.  The fate of massive autogenous and homogenous bone grafts including articular surfaces. , 1954, Surgery, gynecology & obstetrics.

[22]  T. Malinin,et al.  Limb salvage with osteoarticular allografts after resection of proximal tibia bone tumors. , 1998, Clinical orthopaedics and related research.

[23]  F. F. Parrish.  Treatment of bone tumors by total excision and replacement with massive autologous and homologous grafts. , 1966, The Journal of bone and joint surgery. American volume.

[24]  H. Mankin,et al.  Operational and financial aspects of a hospital bone bank. , 1981, The Journal of bone and joint surgery. American volume.

[25]  W. Enneking,et al.  Immunologic Responses in Human Recipients of Osseous and Osteochondral Allografts , 1996, Clinical orthopaedics and related research.

[26]  R. Henshaw,et al.  Review of Endoprosthetic Reconstruction in Limb-sparing Surgery , 2004 .

[27]  H. Mankin,et al.  2. IMMUNOLOGY OF BONE ALLOGRAFTS: CURRENT KNOWLEDGE , 1998 .

[28]  M. Gebhardt,et al.  The use of bone allografts for limb salvage in high-grade extremity osteosarcoma. , 1991, Clinical orthopaedics and related research.

[29]  H J Mankin,et al.  Long-term follow-up of patients with osteochondral allografts. A correlation between immunologic responses and clinical outcome. , 1999, The Orthopedic clinics of North America.

[30]  G. Rosen,et al.  Endoprosthetic replacement for stage IIB osteosarcoma. , 1991, Clinical orthopaedics and related research.

[31]  D. Harlan,et al.  BRIEF HISTORY OF THE UNITED STATES NAVY TISSUE BANK AND TRANSPLANTATION PROGRAMME.: CAPTAIN KENNETH SELL'S LIVING LEGACY , 1998 .

[32]  J. Makley.  The use of allografts to reconstruct intercalary defects of long bones. , 1985, Clinical orthopaedics and related research.

[33]  M. Dominkus,et al.  Growth Prediction in Extendable Tumor Prostheses in Children , 2001, Clinical orthopaedics and related research.

[34]  D.,et al.  Regression Models and Life-Tables , 2022 .

[35]  V. Goldberg,et al.  Factors Affecting Bone Graft Incorporation , 1996, Clinical orthopaedics and related research.

[36]  W. Enneking,et al.  Allograft‐Prosthesis Composite Versus Megaprosthesis in Proximal Femoral Reconstruction , 1996, Clinical orthopaedics and related research.

[37]  R. Henshaw,et al.  Distal Femur Resection With Endoprosthetic Reconstruction: A Long-Term Followup Study , 2002, Clinical orthopaedics and related research.

[38]  M. Gebhardt,et al.  Management of infected bulk allografts with antibiotic-impregnated polymethylmethacrylate spacers. , 2001, Orthopedics.

[39]  H. Mankin,et al.  Osteoarticular and intercalary allograft transplantation in the management of malignant tumors of bone , 1982, Cancer.

[40]  J. Eckardt,et al.  Endoprosthetic reconstruction after bone tumor resections of the proximal tibia. , 1991, The Orthopedic clinics of North America.

[41]  L. Aponte-Tinao,et al.  Survivorship Analysis of 141 Modular Metallic Endoprostheses at Early Followup , 2004, Clinical orthopaedics and related research.

[42]  W. Macewen,et al.  IV. Observations concerning transplantation of bone. Illustrated by a case of inter-human osseous transplantation, whereby over two-thirds of the shaft of a humerus was restored , 1881, Proceedings of the Royal Society of London.

[43]  M. Gebhardt,et al.  Allograft Fractures Revisited , 2001, Clinical orthopaedics and related research.

[44]  I. Stockley,et al.  Allograft bone transplantation: a Sheffield experience. , 1998, Annals of the Royal College of Surgeons of England.

[45]  P. Picci,et al.  Massive Bone Allograft Reconstruction in High-Grade Osteosarcoma , 2000, Clinical orthopaedics and related research.

[46]  M. Neel,et al.  Modular endoprostheses for children with malignant bone tumors. , 2001, Cancer control : journal of the Moffitt Cancer Center.

[47]  E. Kaplan,et al.  Nonparametric Estimation from Incomplete Observations , 1958 .

[48]  J. Scales,et al.  Distal femoral replacement by custom-made prostheses. Clinical follow-up and survivorship analysis. , 1987, The Journal of bone and joint surgery. British volume.

[49]  T. Malinin,et al.  Massive allografts in surgery of bone tumors. , 1989, The Orthopedic clinics of North America.

[50]  K. Heiple,et al.  Bone grafting: Role of histocompatibility in transplantation , 1985, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[51]  H. Mankin,et al.  Blood Transfusion and Bone Allografts: Effect on Infection and Outcome , 1997, Clinical orthopaedics and related research.

[52]  P. Sugarbaker,et al.  Musculoskeletal cancer surgery : treatment of sarcomas and allied diseases , 2001 .

[53]  Transmission of HIV through bone transplantation: case report and public health recommendations. , 1988, MMWR. Morbidity and mortality weekly report.

[54]  P. Cordeiro,et al.  Soft‐Tissue Flap Coverage Maximizes Limb Salvage after Allograft Bone Extremity Reconstruction , 2002, Plastic and reconstructive surgery.

[55]  G. Rosen,et al.  Preoperative chemotherapy for osteogenic sarcoma: Selection of postoperative adjuvant chemotherapy based on the response of the primary tumor to preoperative chemotherapy , 1982, Cancer.

[56]  T. Eastlund.  Infectious Disease Transmission through Cell, Tissue, and Organ Transplantation: Reducing the Risk through Donor Selection , 1995, Cell transplantation.

[57]  M. Malawer,et al.  Limb-sparing surgery for high-grade malignant tumors of the proximal tibia. Surgical technique and a method of extensor mechanism reconstruction. , 1989, Clinical orthopaedics and related research.

[58]  P. Curtiss,et al.  Immunological factors in homogenous-bone transplantation. II. The inability of homogenous rabbit bone to induce circulating antibodies in rabbits. , 1959, The Journal of bone and joint surgery. American volume.