11. COMPARED WITH AMPUTATION AND PROSTHETIC REHABILITATION
SURVIVAL
RECURRENCE
Oscar Pistorius FUNCTION
DURABILITY
COMPLICATIONS
NEOADJUVANT CHEMOTHERAPY
12.
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 Op Staging
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
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
28. osteoid-forming tumor being produced by
osteoblastic cells with a low mitotic index
without an aggressive pattern. This is
compatible with the diagnosis of osteoid
osteoma
34. Wide resection of the 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
73. A total knee implant 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
Preventing loosening by increasing interface
surface between prosthesis and bone
Limiting proximal bone resorption
79. Part of the reconstructive 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.
80.
81.
82.
83.
84.
85. Acetabulum following the resection
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.
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 placed through 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
111. A modified amputation by 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 10 inches 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 has placed 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.
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.
122. COMPOSITE TISSUE ALLOGRAFT
In the 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.
124. LIMB SALVAGE IN CHILDREN
• 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 IN CHILDREN
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 was gradually
lengthened by
inserting and turning
with a metal key via a
one centimetre skin
incision.
Expandable custom-
made tumour
prosthesis.
128. LIMB SALVAGE IN CHILDREN
– 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
130. CLINICAL RESULTS
• Nonmetastatic osteosarcoma 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 of bio 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
The distal femur, knee joint, and proximal tibia are resected, leg is rotated 180 degrees, and the tibia is joined to the remaining femur.
The distalmost femur, knee joint, and proximal tibia are resected. Rotation of 180 degrees, the distal tibia is joined to the distal femur.
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.
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.
The entire femur is resected. The tibia is then attached to the pelvis using an endoprosthesis.