Limb salvage and traumaLimb salvage and trauma Starts at E.R. when a mangledextremity arrives – series ofdecisions1. If life in danger, should the mangledlimb be amputated2. If stable, should an attempt be made tosalvage the mangled limb3. If salvage, what is the sequence ofrepairs4. If salvage fails, when shouldamputation be performed.
Most difficult decisionMost difficult decision Whether to attempt salvage or not 5 Scoring systems publishedAuthor / Year Name CriteriaGregory et al.1985 Mangled ExtremitySyndrome Index9Seiler et al.1986 - 4Howe et al.1987 Predictive Salvage Index PSI 4Johansen et al.1990 Mangled Extremity SeverityScore (MESS)- Prospective4Russell et al.1991 Limb Salvage Index (LSI) 7
Two major criteriaTwo major criteria Immediate amputation Vs attemptedsalvage, if either present- amputationbetter choice.1. Loss of arterial inflow>6 hrs., esp. inpresence of a crushinjury which disruptscollateral vessels.2. Disruption ofposteriortibial nerve.
Relative indications of amputation inRelative indications of amputation inGustilo III-C tibial #sGustilo III-C tibial #s Lange & Hansen et al.Lange & Hansen et al.1. Serious associated polytrauma.2. Severe ipsilateral foot trauma.3. Anticipated protracted course forsoft tissue coverage and tibialreconstruction.If 2 of thesepresentimmediateamputation isrecommended.
Heroic techniques to save a limbHeroic techniques to save a limb If vascular repair satisfactory onarteriogram, but distal extremityborderline viability because of– vascular spasm,– extreme destruction of collateral vesselsin soft tissues or– prolonged ischaemia.1. Sympathetic blocks orsympathectomy of the involved limb.
Tumor and limb salvageTumor and limb salvageAdvances in imaging, chemotherapy,radiotherapy & surgical techniqueTreatment of choice in most boneand soft tissue sarcomas– Preoperative radiation – soft tissuesarcomas– Neoadjuvant chemotherapy – bonesarcomas
Rarely L. S. not possible e.g.Rarely L. S. not possible e.g.Neurovascular structuresinvolvement,Displaced pathological fracture,Complications sec to poorlyperformed biopsy.
Limb salvage / AmputationLimb salvage / AmputationExpectations & desires of theindividual and his family.Simon – 4 Issues– Survival (Mortality)– Morbidity – short & long term– Function – compared to prosthesis– Psychosocial consequences
LiteratureLiteratureSeveral studies of comparison of– Multimodal treatment (Sx + CT)– Amputation– DisarticulationOsteosarcoma– Long term survival 20% to 70%– Local recurrence distal femur lesions 5 –10% equivalent to transfemoralamputations.– Very low in hip disarticulation.
Survival - No study has proved anysuperiority of any surgical techniquecomparing– Limb salvage– Transfemoral amputation or– Hip disarticulationProvided wide surgical marginsobtained.
AmputationAmputationTechnically demanding formalignancy– Non standard flaps– Bone graft augmentation – better fxnallimbComplications– Infection, wound dehiscence– Chronic painful limb, phantom limb– Appositional bone growth – revision.
Limb salvageLimb salvageGreater perioperative and long termmorbidity.– More extensive surgical procedure.– Greater risk of infection & wounddehiscence,– Flap necrosis– Blood loss– DVT
Long term complications– Periprosthetic fractures– Prosthetic loosening or dislocation– Non-union of graft-host junction– Allograft #– LLD & late infectionMultiple future operations.1/3rdof long term survivors –amputations.
Functional outcome:Functional outcome: Location of tumor most important issue. Resection of upper extremity lesion with limbsalvage even sacrificing 1 or 2 major nerves –better fxn – than amputation & prosthetic use. Resection of proximal femoral or pelvic lesionwith local recurrence – better fxn – thandisarticulation or hemipelvectomy. Ankle & foot – amputation + prosthetic fittingbetter in large sarcomas. Sarcomas around knee - individualized.
Osteosarcoma around kneeOsteosarcoma around knee Usually three surgical procedures1. Wide resection with prosthetic kneereplacement,2. Wide resection with allograftarthrodesis &3. Trans femoral amputation. Less commonly,– Osteoarticular allograft reconstruction– Rotationplasty
Compared to transfemoral amputees,pts. having resection & prostheticknee replacement– demonstrated higher self selectedwalking velocities and– a more efficient gait with regards to O2consumption.Otis,lane & kroll
Long term functions for tumorsLong term functions for tumorsabout kneeabout knee Amputation-– difficulty walking on steps, rough, slipperysurfaces but– were active and– least worried about damaging the effectedlimb. Arthrodesis-– performed most demanding physical work &recreational activities– Difficulty in sitting esp. back seat.Harris et al.
Arthroplasty-– generally led more sedentary life & wereprotective of their limb– Little difficulty in ADL– Least self concerned about their limb.A successful arthrodesis is moredurable in long term than a mobilejoint reconstruction.
Allograft-prosthetic compositeAllograft-prosthetic compositereconstructionreconstructionLocation is important.Proximal reconstruction generallyoutlast more distal ones ( Inverse ofprognosis).Prox. femoral > distal femoral > proxtibial.
Leg length discrepancyLeg length discrepancyFuture LLD– Expandable prosthesis– Limb lengthening proceduresComplication may out weigh benefitsesp. in children <10 yrs.– Temporary osteoarticular allograft – tospare the adjacent physis.– Disarticulation and rotationplasty.
Psychological outcomePsychological outcomeNo evidence of any significant diff.Pt must make the final decision– Short & long term goals– Lifestyle modifications.
Margins of tumorMargins of tumor Oncological surgicalprocedures,– margins should bedefined– Amputation /Resection.
Intralesional marginsIntralesional margins Plane of dissectionis within the tumor, Gross residualtumor Symptomaticbenign lesions Debulking Palliativeprocedure inmetastatic disease.
Marginal marginMarginal marginClosest plane of dissection passesthrough the pseudocapsule.Most benign lesionsSome low grade malignanciesSelective high grade malignancies+ preop. radiotherapy and neoadjuvantchemotherapy
Pseudocapsule– containsmicroscopic fociof disease /“satellite” lesions.– Local recurranceif not respondingto C.T. / R.T.
Wide marginsWide marginsPlane of dissection isin normal tissueNo specific distancedefined.Cuff of normal tissueGoal of mostprocedures for highgrade malignancies.
Radical marginsRadical marginsAll compartments thatcontain the tumorremoved en bloc– Soft tissue sarcomas –• removing entirecompartment (or multiplecompartments) of involvedmuscles– Bone tumors-• removing entire bone andthe compartments of anyinvolved ms. *
Oncological standpoint of view:Oncological standpoint of view:8 different surgical procedures– Resection - with 4 types of margins– Amputations - with 4 types of marginsAmputations being usually– wide or radical (high A K amputations)– or may be marginal (Hemipelvectomy).
RESECTION & RECONSTRUCTIONRESECTION & RECONSTRUCTIONCurrent treatment for mostmusculoskeletal malignancies.Aggressive benign neoplasms.Goal of resection:– Wide margin if possible and if not– Marginal margin + C.T. / R.T.• e.g: radiation for soft tissue sarcomas.– Marginal margin - most benign lesions.
ReconstructionReconstruction Allograft arthrodesis still a role insome circumstances. 3 options available for preserving amobile joint:1. Osteoarticular allograft reconstruction2. Endoprosthetic reconstruction3. Allograft prosthesis composite Sometimes rotationplasty.
ComplicationsComplicationsOncological procedures have highercomplications due to– Extensive nature of operations– Extensive tissue loss– Side effects of radiation andchemotherapy– Generally young pts. with high activity.Wound necrosis and infection same.
Osteoarticular allograftsOsteoarticular allografts Adv:– Ability to replace ligaments, tendons &intraarticular structures.– As a temporary measure to preserve adjacentphysis till skeletal maturity e.g. Prox tibia Disadv:– nonunion at graft host jxn.– fatigue #, articular collapse, dislocation,degenerative jt. dis. & failure of ligament &tendon attachments.
Allograft prosthesis compositesAllograft prosthesis composites Long term soln. for some pts. Adv:– Avoid deg. jt disorders and articular collapse– Preserving ability to directly attach soft tissuestructures. Disadv:– fatigue #, infection and non union at graft hostjxn.
Endoprosthetic ReconstructionEndoprosthetic Reconstruction Long term fxn for some pts. Adv:– Predictable immediate stability– Quicker rehab with immediate FWB– Increased durability – better implants.– Incremental limb lengthening Disadv:– Long term compl. if pt. is cured of disease.– polyetheylene wear – inserts replaced.– Fatigue # common at yoke of a rotating hinge –replaceable.– Fatigue # at base of stem – difficult to remove.
Segmental bone and joint prosthesisSegmental bone and joint prosthesis Usually secured through compositefixation Intramedullary stem - fixed with cement –immediate stability quicker rehab. Shoulder region of prosthesis – porouscoating –– promoting late extramedullary corticalbridging– also protecting cement- bone interface &– additional structural support. Bonegrafting at shoulder region topromote extracortical bridging.
Upper Extremity:Upper Extremity: Even the best artificial limbs fail to providecomparable fxn, unlike lower ext. Even with sacrifice of 3 major nerves, limbsalvage is better functional than artificial.– Prox. humeral resection– Axillary N. sacrificed.– Humeral shaft- Radial N. If median & ulnar Ns sacrificed – L.S. isbetter if functioning ms. are available fortransfers.
Resection of shoulder girdleResection of shoulder girdleScapular tumors-– extend to glenohumeral jt.– Extra-articular resection of humeralhead en bloc with scapulaProximal humeral tumors-– Extend into the joint through bicepstendon– Extra-articular partial scapulectomy
Classification: 6 types.Classification: 6 types. TYPE I – Intra-articular prox. humeralresection. TYPE II – Partial scapular resection. Type III – Intra-articular totalscapulectomy. TYPE IV – Extra-articular totalscapulectomy and humeral headresection (Classical Tickhoff Linberg)Malawer et al.
TYPE V –Extra-articular humeralhead resection.TYPE VI - Extra-articular humeraland total scapular resection.Subtypes:– A - Abductor mech. intact.– B - Partial or complete resection.
Tikhoff- Linberg procedure:Tikhoff- Linberg procedure:Total scapulectomyPartial/complete excision of clavicleExcision of prox. humerus.Use:– Malignant tumors about shoulder joint.– Usually sacrificing Axillary N. andsometimes Radial N.
Resection of clavicle:Resection of clavicle:Subcutaneous – early detection.Either end resection.Entire bone excision.Little loss of function.eg. solitary myelomas, ABC, nonspecific granulomatous lesions.
Subtotal resection of scapulaSubtotal resection of scapulaTumors of scapular body wihoutjoint involvement is rare.E.g. Extraabdominal desmoids, GCT,Low grade Chondrosarcoma – PartialscapulectomySubscapularis m. good marginprevents chest wall invasion.
Partial resection of scapulaPartial resection of scapulaParts of scapula to entire bone.E.g. Benign tumors, TB, chronicostemyelitis.Body alone resected – shoulder isfairly stable and functional providedms. are attached in fxnal positions.
Resection of proximal humerus:Resection of proximal humerus:Biopsy - Anterior third of deltoid- nocontamination of delto-pectoralinterval.Used in:– Sarcomas- Resection of prox. humeruswith contiguous soft tissues-satisfactory margins– Aggressive benign neoplasms andmetastatic carcinomas of prox.humerus.
Reconstructive alternatives:Reconstructive alternatives:1. Flial shoulder2. Passive Spacer – Allograft orautograft, fibular or prostheticimplants ( better cosmesis / fxn).3. Arthroplasty (implant or allograft).4. Arthrodesis e.g. Enneking method
Allograftarthrodesis is themost stablereconstuction foryoung pts. Withvigorous activities.
Resection of distal humerusResection of distal humerus Lesions in elbow requiring limb salvageare rare. Occasional malignant/ aggressive benignlesions like Chondroblastoma or GCT. Reconstruction options-– Flial elbow– Osteaoarticular allograft– Implant arthroplasty– Arthrodesis
Resection of proximal radius / ulnaResection of proximal radius / ulnaConsiderable portion can beresected without reconstruction inradius.
Resection of distal radius:Resection of distal radius:E.g. GCTReconstruction by:– Arthroplasty,– Arthrodesis using allograft or auto graft.Proximal fibular auto graftreconstruction arthroplasty– Maintain motion but light activities.Arthrodesis– Sacrifice motion but more stable.
Resection of distal ulnaResection of distal ulnaNo reconstruction needed.Periosteum is excised with thetumor.