Gamble Against Uncertain Odds

By Christine Gorman

For Susan Lazarchick, the decision to undergo an experimental knee transplant was frighteningly simple. A benign tumor the size of a grapefruit was rapidly consuming her right knee and shinbone. Doctors had offered her two other options: amputation, or a bone fusion, which would render her stiff-legged for the rest of her life. She chose the rarely performed transplant. Last week Orthopedic Surgeon Richard Schmidt at the Hospital of the University of Pennsylvania in Philadelphia announced that he had transplanted an entire knee -- bones, cartilage, tendons, ligaments and all -- from an accident victim into the leg of the young New Jersey woman. Schmidt predicts that Lazarchick will one day walk, climb stairs and maybe even dance a step or two.

If the graft takes, Lazarchick, 32, will be numbered among a handful of patients around the world who have undergone at least a partly successful full-knee transplant. More than 100,000 transplants and grafts are performed each year on femurs, skulls and other bones, but replacing an entire knee, a procedure that has been tried on and off since the turn of the century, is especially tricky. Reason: doctors have not been able to save the sensory nerves that monitor the complicated three-dimensional movements of the knee. Explains Dr. Henry Mankin, chief of orthopedics at Massachusetts General Hospital in Boston: "The nerve supply to the joint is crucial. If the nerves are lost, the mechanisms necessary to control the joint are not operative." In the past, attempted whole-knee transplants have resulted in the gradual degeneration of the joint, necessitating an artificial knee, a second graft or even amputation of the leg.

In Lazarchick's case, the potential rewards seemed worth the gamble. "She was young, and we had a frozen graft that perfectly matched her joint," Schmidt says. The hospital's bone bank is one of several hundred nationwide. With prior consent, doctors routinely remove bones from patients who die suddenly, check them for infections such as hepatitis and AIDS, encase them in plastic and store them at -112 degreesF in freezers. Though the living tissue is killed by the extreme cold, the bone's structure survives. Thus, once surgeons implant the new graft, tissue rejection -- the unforgiving nemesis of most transplant attempts -- occurs in only 3% to 5% of cases.

On Sept. 30, Schmidt began the seven-hour operation by cutting a 2 1/2-foot long incision from the middle of his patient's thigh to more than halfway below her knee. He pulled back muscles and nerves, exposed the bones and the tumor; using a surgical saw, he then severed the femur four inches above the knee and the tibia, or shinbone, six inches below it. That done, he lifted out the old joint and tumor, trimmed the carefully chosen donor joint and inserted it into the twelve-inch gap. Using a metal rod and plate, the surgeon secured the new joint to the remainder of the femur and tibia and stitched the thigh muscles to their proper tendons.

Although Lazarchick has been home for five weeks now, her ordeal is far from over. Her leg is still immobilized by a cast, and the threat of infection deep within remains. "If the site gets infected, you lose the transplant," Schmidt warns. "It's way too early to tell if there are going to be any complications," says Dr. Steven Gitelis, director of the bone bank at Chicago's Rush-Presbyterian-St. Luke's Medical Center. The once frozen ligaments and tendons may not properly hold the knee together, and the original cartilage may fail to cushion it from shocks. "I would wait at least a year to proclaim success," he adds. Even so, says Mankin, "I'm all for it. If Schmidt has solved the problems of this operation, I'll be doing it next week."

With reporting by Andrea Dorfman/New York