Bone tumours and principles of limb salvage surgery

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Definition of neoplasia, classification of bone tumors, and principle of limb salvage

Definition of neoplasia, classification of bone tumors, and principle of limb salvage

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  • 1. HYPERPLASIA, METAPLASIA, ANAPLASIAHYPERPLASIA, METAPLASIA, ANAPLASIA NEOPLASIA, TNM CLASSIFICATION AND ITSNEOPLASIA, TNM CLASSIFICATION AND ITS ORTHOPAEDIC APPLICATIONS, SURGICALORTHOPAEDIC APPLICATIONS, SURGICAL CLASSIFICATION, HISTOLOGICCLASSIFICATION, HISTOLOGIC CLASSIFICATION AND PRINCIPLES OF LIMBCLASSIFICATION AND PRINCIPLES OF LIMB SALVAGE SURGERYSALVAGE SURGERY Dr. Sushil PaudelDr. Sushil Paudel
  • 2. NEOPLASIANEOPLASIA  A neoplasm is anA neoplasm is an abnormal mass ofabnormal mass of tissue, growth oftissue, growth of which exceeds & iswhich exceeds & is uncoordinated withuncoordinated with that of the normalthat of the normal tissues **tissues ** **Willis RA; The spread of tumours in the human body. London, Butterworth & Co, 1952
  • 3. HYPERPLASIAHYPERPLASIA  Increase in the number of cells in an organIncrease in the number of cells in an organ or tissueor tissue Physiological hyperplasiaPhysiological hyperplasia Pathological hyperplasiaPathological hyperplasia
  • 4. METAPLASIAMETAPLASIA  Reversible change in which one cell typeReversible change in which one cell type (epithelial or mesenchymal) is replaced by(epithelial or mesenchymal) is replaced by anotheranother Epithelial metaplasiaEpithelial metaplasia Connective tissue metaplasiaConnective tissue metaplasia Eg; Myositis ossificansEg; Myositis ossificans
  • 5. DIFFERENTIATION ANDDIFFERENTIATION AND ANAPLASIAANAPLASIA  Anaplasia is loss of DifferentiationAnaplasia is loss of Differentiation PleomorphismPleomorphism Altered N:C ratioAltered N:C ratio Atypical mitosesAtypical mitoses Tumor giant cellsTumor giant cells
  • 6. DYSPLASIADYSPLASIA  Disordered growthDisordered growth  Loss in the uniformity of individual cells asLoss in the uniformity of individual cells as well as loss in architectural orientationwell as loss in architectural orientation
  • 7. CLASSIFICATION OF BONE TUMORS
  • 8. HISTORYHISTORY  Dates back to 1920, origin of Bone SarcomaDates back to 1920, origin of Bone Sarcoma Registry by Dr CodmanRegistry by Dr Codman  Dr Codman along with James Ewing andDr Codman along with James Ewing and Bloodgod drew up in 1922, the first classificationBloodgod drew up in 1922, the first classification of the Registryof the Registry  Efforts of many pathologists and oncologists hasEfforts of many pathologists and oncologists has given shape to Revised WHO Histologicgiven shape to Revised WHO Histologic Classification of Bone tumours in 1993**Classification of Bone tumours in 1993** **Schajowicz etal,Cancer 1995 Mar
  • 9. Primary tumour (T) TX: primary tumour cannot be assessed T0: no evidence of primary tumour T1: tumour 􀀩 8 cm in greatest dimension T2: tumour > 8 cm in greatest dimension T3: discontinuous tumours in the primary bone site Regional lymph nodes (N) NX: regional lymph nodes cannot be assessed N0: no regional lymph node metastasis N1: regional lymph node metastasis Note: Regional node involvement is rare and cases in which nodal status is not assessed either clinically or pathologically could be considered N0 instead of NX or pNX. Distant metastasis (M) MX: distant metastasis cannot be assessed M0: no distant metastasis M1: distant metastasis M1a: lung M1b: other distant sites TNM CLASSIFICATIONTNM CLASSIFICATION
  • 10. Translation table for ‘three’ and ‘four grade’ to ‘two grade’ (low vs. high grade) system TNM two grade system Three grade systems Four grade systems Low grade Grade 1 Grade 1 Grade 2 High grade Grade 2 Grade 3 Grade 3 Grade 4 Note: Ewing sarcoma is classified as high grade. Stage IA T1 N0,NX M0 Low grade Stage IB T2 N0,NX M0 Low grade Stage IIA T1 N0,NX M0 High grade Stage IIB T2 N0,NX M0 High grade Stage III T3 N0,NX M0 Any grade Stage IVA Any T N0,NX M1a Any grade Stage IVB Any T N1 Any M Any grade Any T Any N M1b Any grade HISTOPATHOLOGICAL GRADINGHISTOPATHOLOGICAL GRADING
  • 11. BenignBenign  LatentLatent  ActiveActive  AggressiveAggressive MalignantMalignant  Stage IA-Low grade,Stage IA-Low grade, intracompartmentalintracompartmental  Stage IB-Low grade,Stage IB-Low grade, extracompartmentalextracompartmental  Stage IIA-High grade,Stage IIA-High grade, intracompartmentalintracompartmental  Stage IIB-HighStage IIB-High grade,extracompartmentalgrade,extracompartmental  Stage III - MetastaticStage III - Metastatic ENNEKING STAGINGENNEKING STAGING
  • 12. WHO HISTOLOGICALWHO HISTOLOGICAL CLASSIFICATIONCLASSIFICATION  Osteogenic tumoursOsteogenic tumours  Cartilage tumoursCartilage tumours  Fibrogenic tumoursFibrogenic tumours  Round cell lesionsRound cell lesions  Giant cell tumour of boneGiant cell tumour of bone  Notochordal tumoursNotochordal tumours  Vascular tumoursVascular tumours  Smooth muscle tumoursSmooth muscle tumours  Lipogenic tumoursLipogenic tumours  Neural tumoursNeural tumours  Miscellaneous tumoursMiscellaneous tumours  Joint lesionsJoint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
  • 13. BONE FORMING (Osteogenic)BONE FORMING (Osteogenic) LESIONSLESIONS BENIGN LESIONSBENIGN LESIONS  OsteomaOsteoma  Enostoses (Bone island)Enostoses (Bone island)  Osteoid osteomaOsteoid osteoma  OsteoblastomaOsteoblastoma
  • 14. MALIGNANT LESIONSMALIGNANT LESIONS  OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from theshare the ability to form osteoid from the neoplastic cellsneoplastic cells MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION  Takes into account etiology, localisation,Takes into account etiology, localisation, bone specific topography and histologybone specific topography and histology
  • 15. PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS  INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA  INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA  SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA  EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
  • 16.  INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA 1. INTRAMEDULLARY1. INTRAMEDULLARY OsteoblasticOsteoblastic ChondroblasticChondroblastic FibrogenicFibrogenic EpithelioidEpithelioid
  • 17.  IMAGINGIMAGING Medullary and cortical bone destruction , aggressive periosteal reaction of the velvet and sunburst types, soft tissue mass contains tumor bone.
  • 18.  HISTOPATHOLOGYHISTOPATHOLOGY Markedly pleomorphic tumor cells are separated by lace-like osteoid
  • 19. 2.MALIGNANT FIBROUS HISTIOCYTOMA2.MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA 3.GIANT CELL RICH OSTEOSARCOMA3.GIANT CELL RICH OSTEOSARCOMA 4.SMALL CELL OSTEOSARCOMA4.SMALL CELL OSTEOSARCOMA 5.LOW GRADE CENTRAL5.LOW GRADE CENTRAL OSTEOSARCOMAOSTEOSARCOMA
  • 20. 6.TELANGIECTATIC OSTEOSARCOMA6.TELANGIECTATIC OSTEOSARCOMA Malignant bone aneurysmMalignant bone aneurysm Aggressive andAggressive and poor prognosispoor prognosis
  • 21. 7.GNATHIC OSTEOSARCOMA7.GNATHIC OSTEOSARCOMA 8.MULTIFOCAL OSTEOSARCOMA8.MULTIFOCAL OSTEOSARCOMA 9. OSTEOSARCOMAS WITH UNUSUAL9. OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS Werner syndrome, Li fraumeni syndrome,Werner syndrome, Li fraumeni syndrome, Blooms syndrome, RetinoblastomaBlooms syndrome, Retinoblastoma syndromesyndrome
  • 22. SECONDARY OSTEOSARCOMAS PAGET SARCOMA FIBROUS DYSPLASIA BONE INFARCT ? POST IRRADIATION
  • 23. CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS BENIGN LESIONSBENIGN LESIONS  CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis –Enchondromatosis – Olliers disease, Mafucci syndromeOlliers disease, Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
  • 24.  OSTEOCHONDROMAOSTEOCHONDROMA Multiple hereditaryMultiple hereditary osteochondromataosteochondromata
  • 25.  CHONDROBLASTOMACHONDROBLASTOMA ( Codman tumor )( Codman tumor ) Preferred site– epiphysisPreferred site– epiphysis  CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA  SYNOVIALSYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
  • 26. MALIGNANT TUMOURSMALIGNANT TUMOURS  CHONDROSARCOMACHONDROSARCOMA PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY CHONDROSARCOMACHONDROSARCOMA Destructive lesion in the medulla with annular and comma shaped calcifications and periosteal new bone formation
  • 27.  CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA  MESENCHYMAL CHONDROSARCOMAMESENCHYMAL CHONDROSARCOMA  MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA  DEDIFFERENTIATED CHONDROSARCOMADEDIFFERENTIATED CHONDROSARCOMA  PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA  SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA  EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
  • 28. SECONDARY CHONDROSARCOMAS ENCHONDROMA OSTEOCHONDROMA PAGETIC BONE SYNOVIAL CHONDROMATOSIS RADIATION INDUCED
  • 29. FIBROGENIC, FIBROOSSEOUS ANDFIBROGENIC, FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS BENIGN LESIONS FIBROUS CORTICAL DEFECT AND NON OSSIFYING FIBROMA BENIGN FIBROUS HISTIOCYTOMA PERIOSTEAL DERMOID FIBROUS DYSPLASIA MONOSTOTIC POLYOSTOTIC MC CUNE ALBRIGHT SYNDROME MAZABRAUD SYNDROME OSTEOFIBROUS DYSPLASIA (KEMPSON CAMPANACCI LESION) Decided preference for Tibia DESMOPLASTIC FIBROMA
  • 30. FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA PRIMARY SECONDARY Pagets disease Fibrous dysplasia Bone infarct Chronic sinuses of osteomyelitis
  • 31. ROUND CELL LESIONSROUND CELL LESIONS BENIGN LESIONS LANGERHANS CELL HISTIOCYTOSIS Eusinophilic granuloma Hand Schullers Christian disease Letterer Siwe disease Vertebra plana
  • 32. MALIGNANT LESIONSMALIGNANT LESIONS  EWINGS SARCOMAEWINGS SARCOMA Diaphysis of long bonesDiaphysis of long bones  MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA Non hodgkins lymphomaNon hodgkins lymphoma Hodgkins lymphomaHodgkins lymphoma permeative bone destruction with an aggressive periosteal reaction
  • 33.  MYELOMAMYELOMA (Plasmacytoma)(Plasmacytoma) Most commonMost common primary malignantprimary malignant tumourtumour TYPES
  • 34. VASCULAR LESIONSVASCULAR LESIONS BENIGN LESIONS INTRAOSSEOUS HEMANGIOMA SYNOVIAL HEMANGIOMA CYSTIC ANGIOMATOSIS GLOMUS TUMOUR LYMPHANGIOMA
  • 35. MALIGNANT LESIONS EPITHELOID HEMANGIOENDOTHELIOMA ANGIOSARCOMA HEMANGIOPERICYTOMA
  • 36. UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS GIANT CELL TUMOURGIANT CELL TUMOUR BENIGNBENIGN 20-40 yr, F>M20-40 yr, F>M Epiphyseal region ofEpiphyseal region of long boneslong bones MALIGNANTMALIGNANT Radiolucent, eccentric, expansive, absence of reactive sclerosis
  • 37. MISCELLANEOUS TUMORS ANDMISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS BENIGNBENIGN  SIMPLE BONE CYSTSIMPLE BONE CYST Metaphyseal, central, lack of periosteal reaction
  • 38.  ANEURYSMAL BONEANEURYSMAL BONE CYSTCYST <20 yr, F>M<20 yr, F>M Metaphysis of long bonesMetaphysis of long bones  SOLID VARIANT OFSOLID VARIANT OF ANEURSYMAL BONEANEURSYMAL BONE CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma Radiolucent, eccentric, expansive, butress of periosteal reaction
  • 39. MALIGNANT LESIONSMALIGNANT LESIONS  ADAMANTINOMAADAMANTINOMA  CHORDOMACHORDOMA  LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
  • 40. rr OSSEOUS METASTASES SOLITARY MULTIPLE CORTICAL
  • 41. PRINCIPLES OF LIMB SALVAGEPRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
  • 42. DEFINITIONDEFINITION ** HENRY DEGROOT et al, LIMB SALVAGE FOR EXTREMITY SARCOMAS** HENRY DEGROOT et al, LIMB SALVAGE FOR EXTREMITY SARCOMAS A set of surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic, functional, and cosmetic result**
  • 43. HISTORY AND CHANGINGHISTORY AND CHANGING TRENDTREND  Eiselberg in 1897Eiselberg in 1897  LexerLexer  11stst successful series of 6 patientssuccessful series of 6 patients  LexerLexer  concept of using allografts in tumor surgeryconcept of using allografts in tumor surgery (1907)(1907)  Major changes since 1970 with the advent of advancedMajor changes since 1970 with the advent of advanced imaging, chemotherapy and radiotherapy, improvedimaging, chemotherapy and radiotherapy, improved surgical techniquessurgical techniques  Limb salvage possible in up to 85% cases**.Limb salvage possible in up to 85% cases**. **Bacci G, Picci 2, Pignatti G,etal**Bacci G, Picci 2, Pignatti G,etal
  • 44. INDICATIONINDICATION  Every patient with tumor of the extremityEvery patient with tumor of the extremity should be considered for limb salvage ifshould be considered for limb salvage if the tumor can be removed with anthe tumor can be removed with an adequate margin and the resulting limb isadequate margin and the resulting limb is worth savingworth saving  No justification for limiting the limb salvageNo justification for limiting the limb salvage process based only on the prognosisprocess based only on the prognosis
  • 45. BARRIERS TO LIMBBARRIERS TO LIMB SALVAGESALVAGE  Poorly placed biopsy incisionsPoorly placed biopsy incisions  Major Neurovascular involvementMajor Neurovascular involvement  Displaced pathologic fractureDisplaced pathologic fracture  Fungating and infected tumorsFungating and infected tumors  Recurrence of malignant tumorsRecurrence of malignant tumors  Inability to afford chemotherapyInability to afford chemotherapy
  • 46.  Vascular involvement is not an absoluteVascular involvement is not an absolute contraindication for limb salvage surgerycontraindication for limb salvage surgery as vascular homografts can be used foras vascular homografts can be used for reconstruction (bypass surgery) **reconstruction (bypass surgery) **  In selected cases limb salvage can beIn selected cases limb salvage can be combined with metastatectomycombined with metastatectomy **Faenza A et al, Transplant Proc 2005:37(6):2692-3**Faenza A et al, Transplant Proc 2005:37(6):2692-3
  • 47.  BoneBone  NervesNerves  VesselsVessels  Soft tissue envelopeSoft tissue envelope If three of these key components areIf three of these key components are involved, the limb salvage is probablyinvolved, the limb salvage is probably not worth consideringnot worth considering THREE STRIKE RULE
  • 48. GOALGOAL  Painless limbPainless limb  Functional, tumor free limbFunctional, tumor free limb  Good psychological outcomeGood psychological outcome
  • 49. SUCCESSSUCCESS Early Management and ReferralEarly Management and Referral Work up – MultidisciplinaryWork up – Multidisciplinary StagingStaging Patient EducationPatient Education Surgical resection and ReconstructionSurgical resection and Reconstruction
  • 50. STAGINGSTAGING Histogenic type of tumor Local extent Possibility of metastasis Radiological staging Surgical staging  The most important step in formulating aThe most important step in formulating a treatment plantreatment plan
  • 51. RADIOLOGICAL STAGINGRADIOLOGICAL STAGING  Probable diagnosisProbable diagnosis  Define the anatomic extent of the lesionDefine the anatomic extent of the lesion  MetastasisMetastasis
  • 52. RADIOGRAPHYRADIOGRAPHY  Site and number of lesionsSite and number of lesions  Location in boneLocation in bone  Type of destructionType of destruction  Soft tissue massSoft tissue mass  Matrix of tumourMatrix of tumour
  • 53. CT SCANCT SCAN  Evaluation of cortical penetrationEvaluation of cortical penetration  Osseous detailsOsseous details  Detecting pulmonary metastasisDetecting pulmonary metastasis
  • 54. MRIMRI  Evaluation of the intra-medullary extent ofEvaluation of the intra-medullary extent of the tumorthe tumor  Soft tissue componentSoft tissue component  Relationship to neurovascularRelationship to neurovascular structuresstructures  Skip lesionsSkip lesions  Plan the surgical marginsPlan the surgical margins
  • 55. ANGIOGRAPHYANGIOGRAPHY  Difficult anatomic locationDifficult anatomic location  Limb salvage surgery where someLimb salvage surgery where some neurovascular bundle must be sacrificed andneurovascular bundle must be sacrificed and reconstructedreconstructed  Micro vascular surgeryMicro vascular surgery  Intra-arterial chemotherapyIntra-arterial chemotherapy  Pre operative EmbolisationPre operative Embolisation
  • 56. SCINTIGRAPHYSCINTIGRAPHY Tech 99m MDPTech 99m MDP  Estimate the local intramedullary extentEstimate the local intramedullary extent  Screen for other skeletal areas ofScreen for other skeletal areas of involvementinvolvement TL- 201 and DMSAVTL- 201 and DMSAV  Differentiation of primary & metastaticDifferentiation of primary & metastatic lesions, benign & malignant cartilage lesionslesions, benign & malignant cartilage lesions
  • 57. PET SCANPET SCAN  Effect ofEffect of chemotherapychemotherapy (Necrosis of tumor(Necrosis of tumor mass)mass)  Investigation ofInvestigation of choice for metastaticchoice for metastatic lesions with unknownlesions with unknown primary lesionprimary lesion  Residual tumorResidual tumor  Recurrence of tumorRecurrence of tumor
  • 58. SURGICAL STAGINGSURGICAL STAGING  FNAC or Needle biopsyFNAC or Needle biopsy  Core biopsyCore biopsy  Incisional biopsyIncisional biopsy  Excisional biopsyExcisional biopsy  BIOPSYBIOPSY Accurate diagnosisAccurate diagnosis Histological gradeHistological grade
  • 59. PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY Total excision of the tract Longitudinal incision
  • 60. Work through muscle not anatomical plane Drain in the line of incision Oval window
  • 61. RESTAGING AFTER PRE OPRESTAGING AFTER PRE OP ADJUVANT THERAPYADJUVANT THERAPY Indicators for favorable responseIndicators for favorable response  ↓↓ tumor volumetumor volume  ↓↓ in angiographic vascularityin angiographic vascularity  Changes in plain X-ray/CT and/or MRI patternsChanges in plain X-ray/CT and/or MRI patterns of matrix appearanceof matrix appearance PET scans are better than MRI & CT for depictingPET scans are better than MRI & CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
  • 62. PRINCIPLESPRINCIPLES  Resection of tumorResection of tumor  Skeletal reconstructionSkeletal reconstruction  Soft tissue & muscle transferSoft tissue & muscle transfer
  • 63. RESECTIONRESECTION SURGICAL MARGINSSURGICAL MARGINS  IntralesionalIntralesional  MarginalMarginal  Wide resectionWide resection  Radical resectionRadical resection (As described by Enneking)
  • 64.  Exactly what constitutes an adequateExactly what constitutes an adequate margin in any particular case remainsmargin in any particular case remains controversialcontroversial  For high grade sarcomas, a wide margin isFor high grade sarcomas, a wide margin is considered adequateconsidered adequate  In low grade tumors or in high gradeIn low grade tumors or in high grade tumors where preoperative radiationtumors where preoperative radiation therapy has been given, a marginaltherapy has been given, a marginal margin may be adequate.margin may be adequate.
  • 65. Tumor resection Margin Curetting of the tumor site Burring of the resected tumor site Lavaging with Adjuvants & curetting
  • 66. SURGICAL ADJUVANTSSURGICAL ADJUVANTS  Local physical or chemical agentsLocal physical or chemical agents CryosurgeryCryosurgery Methacrylate augmentationMethacrylate augmentation Nitrogen mustard, Merthiolate, HypertonicNitrogen mustard, Merthiolate, Hypertonic salinesaline Carbolic acidCarbolic acid High concentration ethanolHigh concentration ethanol Bisphosphonates in Giant cell tumor of boneBisphosphonates in Giant cell tumor of bone
  • 67.  Chemotherapy – Neoadjuvant or AdjuvantChemotherapy – Neoadjuvant or Adjuvant  RadiotherapyRadiotherapy  ImmunotherapyImmunotherapy Specific – Active and PassiveSpecific – Active and Passive Nonspecific – IFN and CSF’sNonspecific – IFN and CSF’s
  • 68. RECONSTRUCTIONRECONSTRUCTION  ArthrodesisArthrodesis  Osteoarticular allograftOsteoarticular allograft  Endoprosthetic replacementEndoprosthetic replacement  Allograft Prosthetic compositeAllograft Prosthetic composite  RotationplastyRotationplasty  Autoclaved tumor boneAutoclaved tumor bone
  • 69. ARTHRODESISARTHRODESIS  With acute docking and shorteningWith acute docking and shortening  With bone graftingWith bone grafting  AllograftAllograft  Autograft (fibula,iliac crest,ribs)Autograft (fibula,iliac crest,ribs)  Autoclaved bone tumour graftAutoclaved bone tumour graft FIXATION INTERNAL Long ILN Plating EXTERNAL Ilizarov External fixator Charnleys clamp
  • 70. ALLOGRAFTALLOGRAFT
  • 71.  Advantages:Advantages:  Length can be adjustedLength can be adjusted  Biological soft tissueBiological soft tissue healinghealing  Avoid the risks andAvoid the risks and complications ofcomplications of intramedullary fixation ofintramedullary fixation of endoprosthesis.endoprosthesis.  Direct attachment ofDirect attachment of remaining musculature.remaining musculature.  Disadvantages:Disadvantages:  Long healing timeLong healing time  Potential for transfer ofPotential for transfer of disease and infectiondisease and infection  Immune rejectionImmune rejection  Necessity of articular surfaceNecessity of articular surface size matchingsize matching  FractureFracture  InfectionInfection  Non-unionNon-union
  • 72. AUTOGRAFTAUTOGRAFT
  • 73. VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT  Can heal in hostile environment (IrradiatedCan heal in hostile environment (Irradiated tissue and active infection)tissue and active infection)  Addresses the complications such as hostAddresses the complications such as host allograft nonunion and allograft fracture**allograft nonunion and allograft fracture** **The Journal of Bone and Joint Surgery (American). 2008;90:93-100.
  • 74. ENDOPROSTHESISENDOPROSTHESIS MEGAPROSTHESISMEGAPROSTHESIS  Large metallic device designed to replaceLarge metallic device designed to replace the excised length of bone and thethe excised length of bone and the adjacent jointadjacent joint  Modified hinge designModified hinge design
  • 75. Proximal femoral prosthesis Saddle prosthesis
  • 76. Proximal humeral prosthesis Proximal tibial prosthesis Distal femoral prosthesis
  • 77. AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
  • 78. ALLOGRAFT PROSTHETICALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE  Allograft provides aAllograft provides a source of bone stocksource of bone stock & site for tendon& site for tendon insertions, while theinsertions, while the prosthesis provides aprosthesis provides a reliable & stablereliable & stable articulation & somearticulation & some support for allograftsupport for allograft
  • 79. ROTATIONPLASTYROTATIONPLASTY  Amputation of the legAmputation of the leg above the knee, lowerabove the knee, lower leg and foot are rotatedleg and foot are rotated 180 degrees, tibia is180 degrees, tibia is then fused to thethen fused to the proximal femur. Theproximal femur. The ankle now functions inankle now functions in place of the knee jointplace of the knee joint
  • 80. LIMB SALVAGE IN UPPERLIMB SALVAGE IN UPPER EXTREMITYEXTREMITY  HANDHAND  WRIST – Arthrodesis or ReconstructionWRIST – Arthrodesis or Reconstruction  ELBOW – ReconstructionELBOW – Reconstruction  HUMERUS – Arthrodesis orHUMERUS – Arthrodesis or ReconstructionReconstruction  SCAPULA - Scapulectomy orSCAPULA - Scapulectomy or ReconstructionReconstruction
  • 81. LIMB SALVAGE IN LOWERLIMB SALVAGE IN LOWER EXTREMITYEXTREMITY  ANKLE – Arthrodesis or ReconstructionANKLE – Arthrodesis or Reconstruction  KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction  FEMUR – Arthrodesis or ReconstructionFEMUR – Arthrodesis or Reconstruction  PELVIS – Resection and Arthrodesis orPELVIS – Resection and Arthrodesis or ReconstructionReconstruction
  • 82. LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN  RotationplastyRotationplasty  Tibial turn upTibial turn up ( Turno plasty)( Turno plasty)  Modular ExpandableModular Expandable prosthesis**prosthesis** **Michael D Neel etal, Cancer control Aug 2001
  • 83. CONCLUSIONCONCLUSION  Limb salvage has become accepted standardLimb salvage has become accepted standard care of the patients with malignant bone tumorscare of the patients with malignant bone tumors  Success depends on prompt and early referralSuccess depends on prompt and early referral by primary care doctor and on careful andby primary care doctor and on careful and coordinated sequencing of events.coordinated sequencing of events.  Achieving a surgical margin that will ensure aAchieving a surgical margin that will ensure a low rate of local recurrence is paramount.low rate of local recurrence is paramount.  Multidisciplinary approach is requiredMultidisciplinary approach is required