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Limb salvage
The document discusses various techniques for limb salvage surgery following bone tumors. It describes the principles of limb salvage compared to amputation, including survival, recurrence, function, and complications. Various reconstruction options after tumor resection are summarized, including allografts, vascularized bone grafts, prosthetics, arthrodesis, rotationplasty, and total femur replacement. Specific case examples illustrate different reconstruction techniques for various tumor locations.
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Overview of limb salvage approach and its significance in orthopaedic practices.
In the 1970s, amputation was the standard treatment for limb conditions.
Key principles include comparisons with amputation, contraindications, and surgical evaluations.
Discusses resection, fixation methods like external fixators, and use of autografts.
Various reconstruction methods like autografts, bone cement, and allografts are explored.Challenges in allografting such as infection risks and incorporation issues.
Discussion on reconstructive approaches following tumor resections in cases like osteoid osteoma.
Advantages of allografts including incorporation into host tissue and better function post-surgery.Focus on prosthetic reconstruction techniques with notable outcomes for various limb salvage cases.
Utilization of composite grafts combining allografts and prosthetics for better function.
Specific strategies for limb salvage in children including biologic and non-biologic methods.
Presentation of clinical results, recurrence rates, and advances in limb salvage techniques.
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Limb salvage
- 1. Department of Orthopaedics MH Kirkee SEMINAR LIMB SALVAGE Maj Rohit Vikas Resident
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- 3. 1970s amputation was standardtreatment
- 10. LIMB SALVAGE PRINCIPLES
- 11. COMPARED WITH AMPUTATIONAND PROSTHETIC REHABILITATION SURVIVAL RECURRENCE Oscar Pistorius FUNCTION DURABILITY COMPLICATIONS NEOADJUVANT CHEMOTHERAPY
- 13. CONTRAINDICATIONS BARRIERS TO LIMB SALVAGE Relative Contraindications to Limb-Sparing Procedures Major neurovascular structures encased by tumor when vascular bypass is not feasible Pathologic fracture with hematoma violating compartment boundary Inappropriately performed biopsy or biopsy-site complications Severe infection in the surgical field Immature skeletal age with predicted leg-length discrepancy >8 cm Extensive muscle or soft-tissue involvement Poor response to preoperative chemotherapy
- 14. Clinical Evaluation Pre OpStaging Biopsy Principles Neoadjuvant Chemotherapy Tumour Resection Avoiding local recurrence is the criterion of success Wide Resection En bloc removal of all biopsy sites contaminated tissue Adequate margins Resection of bone 3 to 4 cm beyond abnormal uptake Frozen Section Skeletal Reconstruction Reconstruction of Soft Tissue and Wound Cover Post op Chemotherapy
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- 16. EXTERNAL FIXATOR INTRAMEDULLARY NAIL BONE GRAFTS INTERNAL FIXATION Dual fibular autografts
- 18. Chondrosarcoma, primary central- Distal femur
- 21. LIMB SALVAGE RESECTION +RECONSTRUCTION AUTOGRAFT
- 22. LIMB SALVAGE RESECTION +RECONSTRUCTION BONE CEMENT
- 24. LIMB SALVAGE RESECTION +RECONSTRUCTION ALLOGRAFT
- 25. INTERCALARY ALLOGRAFT RECONSTRUCTION Disadvantages High rates of infection, nonunion, # of allograft. Adjuvant chemo slows allograft incorporation Transmission of infections Slow remodelling – hardware used cannot be removed 80% good results
- 27. Osteoid Osteoma + Osteogenicsarcoma, intracortical - Femur
- 28. osteoid-forming tumor beingproduced by osteoblastic cells with a low mitotic index without an aggressive pattern. This is compatible with the diagnosis of osteoid osteoma
- 29. Painful recurrence witha lytic area twice as large as the original nidus.
- 30. A neoplastic osteoidformation by osteoblastic cells that have the appearance of an low grade osteosarcoma.
- 31. Cortical allograft inposition following resection of 70% of the diaphysis of the femur with a side plate for stability.
- 32. Osteogenic sarcoma, intracortical- Distal humerus
- 34. Wide resection ofthe distal portion of the humeral diaphysis was carried out, leaving the elbow joint intact. The defect was reconstructed with an allograft fixed into postion with a recon plate. ADVANTAGES Availability in all sizes and shapes Progressive incorporation into host bone Conventional arthroplasty instead of custom made prosthesis Attachment sites available for resected muscles and joint stabilisers – better function No donor site morbidity Failed allograft – further options available
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- 36. GCT – ExtendedCurettage + PMMA Replaced with a hemicondylar Lateral compartment degeneration osteoarticular allograft.
- 37. LIMB SALVAGE RESECTION +RECONSTRUCTION VASCULARISED BONE GRAFT
- 39.
- 40. Radiation associated ST# Femur with Nonunion managed with Vascularised fibular Graft
- 41. LIMB SALVAGE RESECTION +RECONSTRUCTION PROSTHESIS
- 42. PROSTHETIC RECONSTRUCTION • Advantage– earliest mobilisation and weight bearing • 10-year survival of modular prosthesis for – Distal femur – 90%. – Proximal humerus – 98%. – Proximal femur – 100%. – Proximal tibia – 78%.
- 44. ONCO PROSTHESIS FORPROXIMAL FEMUR Fibrosarcoma - Femur
- 45. ONCO PROSTHESIS FORPROXIMAL FEMUR Fibrosarcoma - Femur
- 46. ONCO PROSTHESIS FORPROXIMAL FEMUR Fibrosarcoma - Femur
- 47. ONCO PROSTHESIS FORPROXIMAL FEMUR Fibrosarcoma - Femur
- 48. ONCO PROSTHESIS FORPROXIMAL FEMUR Fibrosarcoma - Femur
- 49. ONCO PROSTHESIS FORPROXIMAL FEMUR Radiation associated Fracture of Proximal Femur
- 50. ONCO PROSTHESIS FORDISTAL FEMUR Osteosarcoma - Femur
- 51. ONCO PROSTHESIS FORDISTAL FEMUR Osteosarcoma - Femur
- 52. ONCO PROSTHESIS FORDISTAL FEMUR Osteosarcoma - Femur
- 53. ONCO PROSTHESIS FORDISTAL FEMUR Osteosarcoma - Femur
- 54. ONCO PROSTHESIS FORDISTAL FEMUR Osteosarcoma - Femur
- 55. ONCO PROSTHESIS FORDISTAL FEMUR Osteosarcoma - Femur
- 56. ONCO PROSTHESIS FORDISTAL FEMUR Chondrosarcoma – Dedifferentiated ,Femur
- 57. ONCO PROSTHESIS FORDISTAL FEMUR
- 58. ONCO PROSTHESIS FORDISTAL FEMUR
- 59. ONCO PROSTHESIS FORDISTAL FEMUR
- 60. ONCO PROSTHESIS FORDISTAL FEMUR Recalcitrant Non union of Radiation associated Fracture SC Femur
- 61. ONCO PROSTHESIS FORDISTAL FEMUR TMH-NICE (New Indigenous Customised Endoprosthesis)joint
- 62. ONCO PROSTHESIS FORPROXIMAL HUMERUS
- 63. Osteosarcoma of scapula.Unconstrained total scapular prosthesis with cemented humeral component used for limb salvage.
- 64.
- 65. LIMB SALVAGE RESECTION + RECONSTRUCTION ALLOGRAFT PROSTHESIS COMPOSITE Attachment sites available for resected muscles and joint stabilisers – better function
- 68. Combined allograft and cementedNeer prosthesis
- 71. Low-grade cartilaginous tumorbut with areas in the central portion that show osteoid being produced by the tumor as well
- 72. Osteogenic sarcoma, periosteal- Proximal tibia
- 73. A total kneeimplant with an allograft placed over the proximal portion of the tibial component and a short side plate to control rotation of the allograft.
- 74. Restoring bone stock Preventingloosening by increasing interface surface between prosthesis and bone Limiting proximal bone resorption
- 75. LIMB SALVAGE RESECTION +RECONSTRUCTION AUTOCLAVED BONE GRAFT +/- PROSTHESIS
- 76. Malignant fibrous histiocytoma- Proximal humerus
- 79. Part of thereconstructive procedure consists of autoclaving the surgical specimen at 130 degrees centigrade for 4 min. This kills the tumor but preserves the physical aspects of the bone, which is then placed back over a long-stem Neer prosthesis and cemented into position.
- 85. Acetabulum following theresection showing the hyperemic changes in the acetabular synovial tissues, a response to the antigen stimulation of the nearby tumor in the upper femur. There is no crossover into the acetabular structures preventing the need for a more aggressive internal hemipelvectomy reconstruction.
- 88. Osteogenic sarcoma, classic- Pelvis
- 89. Internal hemipelvectomy The specimen was debulked of the major tumor mass which was sent to pathology. The remaining bone was placed in the autoclave for 5 minutes at 130°C and placed back into the patient's pelvis for reconstructive purposes.
- 90. Pins were placedthrough the autoclaved autograft along with screws and plates. A routine total hip prosthesis was cemented into position on Entire acetabulum recemented in anatomical position that top of the threaded Steinmann pins. allows for excellent weight bearing function
- 92. LIMB SALVAGE RESECTION +RECONSTRUCTION TOTAL FEMUR
- 93. Ewing's sarcoma –Femur With Pathological fracture from biopsy site
- 97. Custom total femoralimplant
- 98. LIMB SALVAGE RESECTION +RECONSTRUCTION ROTATIONPLASTY
- 99. ROTATIONPLASTY • Group AI—Distal Femur.
- 100.
- 101. ROTATIONPLASTY • Group BI—Proximal Femur sparing the hip joint and gluteal muscles.
- 102. ROTATIONPLASTY • Group BII—Proximal Femur with involvement of hip joint and contiguous soft tissue.
- 103. ROTATIONPLASTY • Group BIII—Lesionin midfemur.
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- 105.
- 106.
- 107.
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- 109.
- 111. A modified amputationby means of a Van Ness turn-up-plasty. Bone amputation level is high above the tumor in the proximal femur but the soft tissue amputation is distal just above the knee, utilizing the proximal tibia as a vascularized graft. The tibia is turned upside down into the defect created by the bone resection, leaving the patient with a functional end result similar to a routine supracondylar amputation. Traditional design of the skin flaps for a supracondylar amputation.
- 112. The proximal 10inches of the tibia has been mobilized from its surrounding soft tissue, leaving only the anterior compartment and the deep posterior compartment intact. The popliteal vessels are intact proximally just beneath the tibial plateau, still supplying vascular nutrition to the resected tibia.
- 113. The surgeon hasplaced the proximal 10 inches of the tibia upside down into the thigh with a sideplate utililized proximally to fix the distal part of the tibia to the proximal part of the femur. We are looking directly at the tibial plateau surface of the knee joint that now acts as the distal end of the femoral stump to replace the resected distal femur. The resected distal femur and its tumor content is seen lying next to the wound.
- 115. LIMB SALVAGE RESECTION + LIMB LENGTHENING
- 117.
- 118.
- 119. LIMB SALVAGE COMPOSITE TISSUE ALLOGRAFT
- 120. COMPOSITE TISSUE ALLOGRAFT First hand transplant by Dubernard et al in 1998 More than 100 CTA transplantations have been performed since 1998 These transplantations have included the upper extremity, laryngeal tissue, abdominal wall, face, bone, joint, uterus, nerve, tongue, and genitals. Still an experimental reconstructive procedure.
- 121. COMPOSITE TISSUE ALLOGRAFT Skin- most antigenic and immunoreactive tissue in CTA
- 122. COMPOSITE TISSUE ALLOGRAFT Inthe United States, 5 hands have been transplanted in five patients since 1999 at the University of Louisville 3 hands have been transplanted in two patients at the University of Pittsburgh Medical Center in 2009. Composite Tissue Allotransplantation. Available at: http://www.handtransplant.com/. Accessed December 30,2009. Successful Hand Transplants Performed. Available at: http://www.mirm.pitt.edu/ news/article.asp?qEmpID=434. Accessed December 30, 2009.
- 123. LIMB SALVAGE IN CHILDREN
- 124. LIMB SALVAGE INCHILDREN • Biologic – Allografts, vascularised autografts – Best for diaphyseal defects but not osteoarticular defects • Nonbiologic – Using a prosthesis – Early weight bearing, joint motion – Expensive ,Complications increase with survival • Combined (biologic and nonbiologic).
- 125. LIMB SALVAGE INCHILDREN Expandable prosthesis • Restoration of limb length desirable – Lower limb • Gait abnormalities, leg pain, and back pain – Upper limb • short arm is cosmetically embarrassing
- 126. The leg wasgradually lengthened by inserting and turning with a metal key via a one centimetre skin incision. Expandable custom- made tumour prosthesis.
- 127.
- 128. LIMB SALVAGE INCHILDREN – Extendable prostheses required when • Estimated leg-length discrepancy at skeletal maturity is more than 3 cm / when the arm-length discrepancy is more than 5 cm. – Girls older than 11 years or boys older than 13 years rarely require extendable prostheses
- 129. LIMB SALVAGE RESULTS
- 130. CLINICAL RESULTS • Nonmetastaticosteosarcoma of distal femur – 11% recurrence with limb salvage – 8% recurrence with AK amputation – No recurrence after hip disarticulation • Rate of local recurrence – 8% for poor histologic responders – 3% for good histologic responders • Most important determinant of local recurrence was the type of surgical margin and the response to chemotherapy.
- 131. ADVANCES • Use ofbio artificial Hydroxyapatite – fixation of bone cells on HA-can be used in lieu of autografts • Osteointegrable prosthesis – Osteoinduction by BMP – Biodegradable synthetic carrier – Polylactate-Polyethylene glycol (PLA- PEG) • Dacron fabric enveloped alumina ceramic prosthesis for large bone defects – for better ancourage of soft tissues • IM nailing instead of plating for fixation of allografts (Endolock, Titanium Dynamic nailing)
Editor's Notes
- #100 The distal femur, knee joint, and proximal tibia are resected, leg is rotated 180 degrees, and the tibia is joined to the remaining femur.
- #101 The distalmost femur, knee joint, and proximal tibia are resected. Rotation of 180 degrees, the distal tibia is joined to the distal femur.
- #102 The upper femur and hip joint are resected, and the leg is rotated 180 degrees. The distal femur is joined to the pelvis so the knee functions as the hip and the ankle as the knee.
- #103 The upper femur, hip joint, and lower hemipelvis are resected, and the leg is rotated 180 degrees. Then the remaining femur is joined to the remnant of the ilium so the knee functions as a hinged hip joint and the ankle functions as the knee.
- #104 The entire femur is resected. The tibia is then attached to the pelvis using an endoprosthesis.