Transplant surgery used to mean kidneys and livers and hearts. But today, these aren't the only body parts finding a new home.
Surgeons are using transplanted tendons and cartilage to rebuild damaged knees, and harvesting bone to shore up aching backs.
Two decades ago, these "musculoskeletal" transplants were rare. Now they're used on more than a million patients a year in the U.S. alone. What many recipients don't know is that these recycled bits of tendon or bone can sometimes make them sick.
'A Season-Ending Injury'
Mahmoud Radwan became aware of the risks of tissue transplants several months ago when he was facing knee surgery that would use a tendon transplanted from a cadaver.
Radwan had been a world-class athlete. He won championships in a type of Kung Fu that includes elements of boxing and wrestling. These days, Radwan is helping his wife run their kiosk in a New Jersey mall.
Radwan says it wasn't Kung Fu that took out his knee. It was an accident at his regular job — as a foreman at a warehouse.
"I was helping a customer," he says. "My leg fell in a pothole of snow and I fell backward and I tear the ACL."
ACL stands for anterior cruciate ligament. For professional athletes, these letters are usually mentioned right before the phrase "season-ending injury." For Radwan, a torn ACL meant an end to his work at the warehouse.
"They took me in the ambulance and they told me my knee, I did severe damage to it," he says.
Radwan says he was OK with the prospect of major knee surgery until he learned that his surgeon wanted to replace the damaged ACL with a tendon from a dead person.
That made him nervous because he'd been reading alarming news reports on the Internet.
"They have people stealing body parts and they actually sell it and it's a big business," he says. "I don't want to have someone else's leg in my leg. So I need to make sure that it's a good one."
Stolen Body Parts
Radwan had reason to worry. A business in New Jersey had been accused of selling body parts stolen from corpses at funeral homes. The case got a lot of attention, especially after it turned out that one of those plundered cadavers was the late Alistair Cooke of Masterpiece Theatre.
The stolen body parts hadn't gone through the usual safety checks, yet they ended up in hundreds of unsuspecting patients, who may have been exposed to a wide range of diseases.
And that's just one incident showing that transplanted body tissues aren't always safe. Perhaps the best known case occurred five years ago.
Lennox Archibald says he investigated the case because he just happened to be on call that day at the Centers for Disease Control and Prevention in Atlanta. His job was to investigate infections that occurred in hospitals or other health-care settings. He got a report about a transplant in Minnesota that went very wrong.
"It was a young man," he says. "I think he was 23. He underwent a knee procedure and within two to three days, he developed symptoms — fever, feeling unwell. And by the time he presented to the emergency room he had a high fever, and he died soon after."
It turned out that the man apparently received cartilage that was contaminated with a nasty bacteria called clostridium. The infection occurred even though the tissue bank involved had apparently followed the rules, Archibald says. He suspected there were other cases, but it was hard to know how many.
"At the time that this fell in my lap," he says, "there was no surveillance system or reporting system for musculoskeletal allograft infections."
Archibald says it didn't take long before CDC investigators began to understand why these infections could occur.
Bones and tendons are usually the last things to be removed from a dead person who has agreed to donate body parts. Organs such as kidneys and livers are usually taken first. And while that's going on, Archibald says, the corpse starts to decompose.
"Within hours, bugs that would ordinarily be eliminated, killed, start proliferating in the bloodstream," he says.
Those bugs may eventually reach tendons and bones and cartilage. Most tissue banks try to eliminate bacteria by soaking the tissues in antibiotics. But that doesn't get rid of viruses or tough bacteria like clostridium.
The Need to Sterilize
Archibald published his findings in the New England Journal of Medicine in 2004. The article concluded that there was a great need to sterilize tissues before transplanting them.
He says the need is even more pressing today, partly because many surgeons already think the bones and tendons they're transplanting have been sterilized.
"You have to bear in mind, these guys are in the operating theater. And they are getting something that is sometimes doubly or triply packaged in [a] nice sort of solution," he says.
By the time the New England Journal article came out, Archibald had left the CDC to join the University of Florida. He also had decided he wanted to do something to make tissue transplants safer.
Archibald became the medical director of a company that had found a way to truly sterilize bones and tendons without damaging them. Since then, a second company has also found a way to safely sterilize tissue.
Doctors are just beginning to offer their patients sterilized transplants. Dr. Alexander Sapega is an orthopedic surgeon in New Jersey. He says he had never been completely comfortable using cadaver tissues.
"For the past 15 years, we've always had a very nagging concern, both on our end as well as the patient's end, about the potential for disease transmission," he says.
Sapega says patients tend to worry about getting hepatitis or HIV. But surgeons know that common bacteria can do a lot of damage even if they don't kill you.
"A simple bacterial infection that is not life-threatening is an extremely nasty thing to deal with in a knee," he says. "It can cause premature arthritis in the knee joint. The toxins emitted by certain types of bacteria can sort of eat away at the cartilage and essentially wreck a knee joint."
'It's Kind of a No-Brainer'
Last year, Sapega began offering his patients a full range of options. They could get old-fashioned surgery that rebuilds the knee using healthy tissue from their own body — which usually means a longer recovery period. Or, they could choose an unsterilized tendon from a cadaver. Or, they could choose a sterilized tendon. Sapega says his patients usually have the same reaction.
"It doesn't seem to take them very long to say, 'Well, gee, if I can have an allograft where I don't have to cut up healthy portions of my knee to fix the bad portions, and yet I don't have to put up with the risk of disease transmission...' It's kind of a no-brainer."
But most surgeons still don't offer sterilized transplants. Fewer than 10 percent of eligible patients receive them.
Mahmoud Radwan, the Kung Fu champion, says he's glad he got his new tendon from Dr. Sapega.
"This one is guaranteed — nothing wrong with it," he says. "I don't want to take that chance. I just want to go with the one I know is good."
Radwan says he's very pleased with the results even though it may take a year for the knee to heal fully.
During a quiet moment at his New Jersey kiosk, Radwan props his foot on a bench and pulls up his pants leg. He points to his scars and gives a brief lecture on exactly how Sapega rebuilt his knee.
"He stripped my muscle, wrapped it on the tibia and screwed it in to hold the side from moving," he says.
Radwan says he expects he'll eventually be getting around pretty much the way he used to.
Sapega wants him to stay away from Kung Fu tournaments, but Radwan says he still has daydreams about competing.
"I was good," he says. "I was very good. I'm still good, but with one leg."