Megaprosthesis limb salvage surgery: Outcome and challenges in treating advanced bone tumour cases in vast archipelago in Indonesia. A case series

Introduction: Limb salvage is considered as a more popular option in Indonesia, as amputation is considered offensive and taboo for many Indonesian cultures and societies. We evaluated the outcome of a series of LSSs with megaprosthesis and their challenges during treatments in Indonesia as the biggest archipelago nation in the world. Methods: Thirty-two patients originated from different islands in Indonesia with advanced lower extremity bone tumours were prospectively reviewed. Data was obtained from surgeries, which was conducted between 2011 and 2015 by two orthopaedic oncologist at Cipto Mangunkusumo Hospital. Functional outcome using musculoskeletal tumour society (MSTS) score and oncological outcome were evaluated manually during every outpatient visit at 3, 6, 12 and 24 months. Results: Eight patients originate from Sumatra, one from Moluccas island, and twenty-three based in the Java island. We documented fourteen osteosarcomas, two cases of metastatic bone disease, fifteen giant cell tumours, and one chondromyxoid fibroma. Compared to preoperative score (mean 5.3, MSTS Score range 0–10), postoperative result (mean 25.2, MSTS Score range 53.3–90) at two year revealed 4.75 fold of improvement. Nearly half of the patient (40.6%) showed excellent score (MSTS Score range 76.6–96.6) after one year. We reported several complications including: infection, knee dislocation, mechanism extensor disturbance, amputation, and nerve injury. Lower MSTS score was correlated with higher serum alkaline phosphatase (SAP) (p = 0,031) and increase intraoperative blood loss (p = 0,033). Complication was found to be associated with tumours that underwent extensive soft tissue reconstruction procedure (p = 0,021). Conclusion: Functional outcome up to 24 months recorded satisfying result. Several complications occurred during our study also passed struggles for our patients during follow up care due to geographical challenges. Nevertheless, for carefully selected patients in Indonesia, LSS with megaprosthesis is an option that technically visible and culturally acceptable.