When and Why Biological/Implant Reconstruction?

Abstract

Limb salvage surgery, which involves resection and reconstruction, is the commonly accepted method of treatment for musculoskeletal tumors today. While reconstruction can be performed by either biological or non-biological methods, tumor resection with safe margins is the minimum requirement for successful limb salvage. Local tumor control must be secured before any reconstruction effort, which will restore the anatomical integrity and function of the limb, since failure to do so will cancel out any seemingly successful reconstructive procedure. Various types of vascular and nonvascular structural autografts, recycled autografts, massive allografts, and distraction osteogenesis are the main tools of biological reconstruction, whereas megaprosthetic implants are the most important means of non-biological reconstruction. Although the indications for each of these methods may vary depending on patient demographics, tumor properties, socioeconomic and psycho-socio-cultural factors, healthcare policies, the capabilities of the medical institution, and finally the skill, knowledge, and experience of the surgeon, most cases can be labeled as more suitable for either biological or non-biological reconstruction in the light of prognostic factors, technical considerations, and short-to-long-term advantages and disadvantages. Some cases, on the other hand, may fall into a “gray-zone” category, where any decision about biological versus non-biological reconstruction and even limb salvage versus amputation is open to debate. Limb-sparing management of these cases requires a genuine understanding of patient expectations, detailed discussion of the risks and benefits of alternative treatment methods, utilization of extensive microsurgical support and other advanced surgical techniques, goal-oriented selection of implants, and a tailored neoadjuvant treatment, which might include unconventional use of chemotherapy and radiotherapy.