Limb Salvage for Long-bone Sarcomas: A Comparative of Clinical Outcomes and Cost-effectiveness Analysis of Biological versus Endoprosthetic Reconstruction

When a malignant tumor takes hold in a long bone, such as the thigh or upper arm, the goal of modern medicine is to remove the cancer while saving the limb. For decades, surgeons have relied on two main strategies to rebuild the missing bone. One approach uses a metal replacement, a custom-made artificial joint that fits into the body immediately after the tumor is cut away. The other uses biological reconstruction, where the surgeon takes bone from another part of the patient's body or a donor, cleans it of living cells, and grafts it back into the gap. This second method is more complex and takes longer to heal, but it uses the body's own tissue rather than a permanent machine. For young patients, who may live for many decades after their cancer is cured, the choice between these two paths matters deeply. It is not just about surviving the surgery, but about how well the leg or arm works twenty or thirty years later, and what the financial burden looks like over a lifetime.

Researchers at The First Affiliated Hospital of Sun Yat-sen University in China set out to compare these two paths directly. They looked back at the records of 1,657 patients who had undergone limb-salvage surgery for bone cancer between 2008 and 2023. To make a fair comparison, they used a statistical method to pair patients who were similar in age, tumor location, and cancer severity, creating two groups of roughly equal size: one group that received the metal replacement and another that received the biological graft. They then tracked these patients for an average of nearly seven years, watching closely for complications, measuring how well they could move, and calculating the total cost of their care from the perspective of the Chinese healthcare system.

The results revealed a clear trade-off between the immediate and the long term. The metal replacement group had an easier start. Their surgeries were shorter, taking about four hours compared to seven hours for the biological group, and they lost less blood during the operation. Because the metal implant provides instant stability, these patients walked better and had higher functional scores just six months after surgery. However, this advantage did not last. As time passed, the biological group caught up and eventually surpassed the metal group. By the end of the study, patients with biological grafts had higher scores for limb function and movement. The metal implants, while sturdy at first, began to show signs of wear and failure more frequently after three years, leading to a higher rate of complications and additional surgeries in the later years of the study. In contrast, the biological grafts, which faced more difficulties in the first few years as they healed, proved more durable over the long haul, with their complication rates dropping significantly after the third year.

Crucially, the study found that neither method gave a patient a better chance of surviving the cancer itself. The rates of the disease returning or the patient passing away were the same for both groups. The difference lay entirely in the quality of life and the cost of care. The biological reconstruction was significantly cheaper. The metal implants themselves cost nearly double the price of the biological materials, and when the researchers added up all the hospital bills, including the costs of managing complications over a lifetime, the biological approach saved the healthcare system a substantial amount of money. When the researchers modeled the future costs and benefits over a patient's entire life, the biological method emerged as the more efficient choice. It cost less, required fewer major revisions in the long run, and resulted in more years of healthy life for the patient.

This study suggests that while the metal replacement offers a quicker recovery and better function in the first year, the biological graft is a more sustainable solution for the decades that follow. For young patients facing a lifetime of activity, the biological approach may offer a stronger, more natural limb that does not degrade over time, all while placing a lighter financial burden on the healthcare system. The findings provide a clear picture for doctors and families weighing these options: if the goal is immediate mobility, the metal implant wins, but if the goal is a durable, cost-effective limb for a long life, the biological graft is the superior path.