Massive Allograft Reconstruction in Limb Salvage Surgery: Insights From a Single-Institution Case Series in Malaysia

Introduction With advances in imaging and oncological treatment, limb salvage surgery has become a preferred option in musculoskeletal oncology. As survival rates improve, reconstruction durability becomes critical. Massive bone allografts offer a biological solution that preserves bone stock and joint integrity, but they are associated with notable complications. This series aims to evaluate the clinical outcomes of massive allograft reconstructions following tumor resections. Methods This is an observational and descriptive review of limb salvage surgeries performed at Penang General Hospital, Malaysia, between 2016 and 2023. It includes a total of 17 patients, comprising 16 individuals diagnosed with primary bone tumors, either malignant or benign but locally aggressive, and one patient who underwent revision surgery for aseptic loosening of a previously implanted prosthesis. All reconstructions were performed using fresh-frozen massive allografts (12 osteoarticular, 5 intercalary) sourced from the Universiti Malaya Medical Centre Bone Bank. Data were collected from medical records, radiographs, and follow-up visits, with limb function evaluated using the Musculoskeletal Tumor Society (MSTS) score. Follow-up ranged from 18 months to nine years. Results The cohort included 13 males and four females, with a mean age of 26.7 years (range: 7-71). Histological diagnoses were osteosarcoma (n = 9), Ewing's sarcoma (n = 3), chondrosarcoma (n = 3), and one giant cell tumor. The patient survival rate was 88.2% (n = 15) at a median follow-up of seven years (range: 3-9 years). Allograft union occurred in 12 cases (70.6%) with a mean time to union of 10.4 months. Four patients developed nonunion, three underwent revision surgery, and one was managed conservatively. Fractures occurred in three patients (17.6%), all requiring osteosynthesis. Infections were reported in three cases, all managed surgically; one case had a delayed onset at 50 months postoperatively. Local recurrence was seen in one patient, necessitating amputation. Seven patients (41.2%) required secondary surgery for complications. Allograft survival rate was 70.6%, and 53% of patients remained complication-free at final follow-up. The mean MSTS functional score (excluding two deceased patients) was 24. Conclusion Massive bone allografts remain a viable and durable option for reconstruction in limb salvage surgery following musculoskeletal tumor resection. Despite a 41.2% reoperation rate due to complications such as nonunion, fracture, and infection, long-term outcomes were acceptable, with satisfactory function achieved in the majority of patients. This method supports preservation of joint structures and bone stock, making it particularly beneficial for young patients with extended survival expectations. Careful patient selection and surgical planning are critical to optimize outcomes.