LIMB SALVAGE SURGERYLIMB SALVAGE SURGERY
Limb SalvageLimb Salvage TRAUMA  TUMOR
Limb salvage and traumaLimb salvage and trauma Starts at E.R. when a mangledextremity arrives – series ofdecisions1. If l...
Most difficult decisionMost difficult decision Whether to attempt salvage or not 5 Scoring systems publishedAuthor / Yea...
Mangled Extremity Severity ScoreMangled Extremity Severity Score
Two major criteriaTwo major criteria Immediate amputation Vs attemptedsalvage, if either present- amputationbetter choice...
Relative indications of amputation inRelative indications of amputation inGustilo III-C tibial #sGustilo III-C tibial #s L...
Heroic techniques to save a limbHeroic techniques to save a limb If vascular repair satisfactory onarteriogram, but dista...
2. Proximal arterial infusion withHeparin – Tolazoline – SalineSolution (1000 U heparin + 500mgtolazoline in 1000ml saline...
TUMOR AND LIMB SALVAGETUMOR AND LIMB SALVAGE
Tumor and limb salvageTumor and limb salvageAdvances in imaging, chemotherapy,radiotherapy & surgical techniqueTreatment...
Rarely L. S. not possible e.g.Rarely L. S. not possible e.g.Neurovascular structuresinvolvement,Displaced pathological f...
Limb salvage / AmputationLimb salvage / AmputationExpectations & desires of theindividual and his family.Simon – 4 Issue...
LiteratureLiteratureSeveral studies of comparison of– Multimodal treatment (Sx + CT)– Amputation– DisarticulationOsteosa...
Survival - No study has proved anysuperiority of any surgical techniquecomparing– Limb salvage– Transfemoral amputation o...
AmputationAmputationTechnically demanding formalignancy– Non standard flaps– Bone graft augmentation – better fxnallimbC...
Limb salvageLimb salvageGreater perioperative and long termmorbidity.– More extensive surgical procedure.– Greater risk o...
Long term complications– Periprosthetic fractures– Prosthetic loosening or dislocation– Non-union of graft-host junction–...
Functional outcome:Functional outcome: Location of tumor most important issue. Resection of upper extremity lesion with ...
Osteosarcoma around kneeOsteosarcoma around knee Usually three surgical procedures1. Wide resection with prosthetic kneer...
Compared to transfemoral amputees,pts. having resection & prostheticknee replacement– demonstrated higher self selectedwa...
Long term functions for tumorsLong term functions for tumorsabout kneeabout knee Amputation-– difficulty walking on steps...
Arthroplasty-– generally led more sedentary life & wereprotective of their limb– Little difficulty in ADL– Least self con...
Allograft-prosthetic compositeAllograft-prosthetic compositereconstructionreconstructionLocation is important.Proximal r...
Leg length discrepancyLeg length discrepancyFuture LLD– Expandable prosthesis– Limb lengthening proceduresComplication m...
Psychological outcomePsychological outcomeNo evidence of any significant diff.Pt must make the final decision– Short & l...
Margins of tumorMargins of tumor Oncological surgicalprocedures,– margins should bedefined– Amputation /Resection.
Orthopedic oncologyOrthopedic oncologyFour terms1.Intralesional2.Marginal3.Wide4.Radical
Intralesional marginsIntralesional margins Plane of dissectionis within the tumor, Gross residualtumor Symptomaticbenig...
Marginal marginMarginal marginClosest plane of dissection passesthrough the pseudocapsule.Most benign lesionsSome low g...
Pseudocapsule– containsmicroscopic fociof disease /“satellite” lesions.– Local recurranceif not respondingto C.T. / R.T.
Wide marginsWide marginsPlane of dissection isin normal tissueNo specific distancedefined.Cuff of normal tissueGoal of...
Radical marginsRadical marginsAll compartments thatcontain the tumorremoved en bloc– Soft tissue sarcomas –• removing ent...
Oncological standpoint of view:Oncological standpoint of view:8 different surgical procedures– Resection - with 4 types o...
RESECTION & RECONSTRUCTIONRESECTION & RECONSTRUCTIONCurrent treatment for mostmusculoskeletal malignancies.Aggressive be...
ReconstructionReconstruction Allograft arthrodesis still a role insome circumstances. 3 options available for preserving...
ComplicationsComplicationsOncological procedures have highercomplications due to– Extensive nature of operations– Extensi...
Osteoarticular allograftsOsteoarticular allografts Adv:– Ability to replace ligaments, tendons &intraarticular structures...
Allograft prosthesis compositesAllograft prosthesis composites Long term soln. for some pts. Adv:– Avoid deg. jt disorde...
Endoprosthetic ReconstructionEndoprosthetic Reconstruction Long term fxn for some pts. Adv:– Predictable immediate stabi...
Segmental bone and joint prosthesisSegmental bone and joint prosthesis Usually secured through compositefixation Intrame...
SURGICAL TECHNIQUESURGICAL TECHNIQUEUpper ExtremityLower Extremity &Pelvis
Upper Extremity:Upper Extremity: Even the best artificial limbs fail to providecomparable fxn, unlike lower ext. Even wi...
Resection of shoulder girdleResection of shoulder girdleScapular tumors-– extend to glenohumeral jt.– Extra-articular res...
Classification: 6 types.Classification: 6 types. TYPE I – Intra-articular prox. humeralresection. TYPE II – Partial scap...
TYPE V –Extra-articular humeralhead resection.TYPE VI - Extra-articular humeraland total scapular resection.Subtypes:– ...
Tikhoff- Linberg procedure:Tikhoff- Linberg procedure:Total scapulectomyPartial/complete excision of clavicleExcision o...
Resection of clavicle:Resection of clavicle:Subcutaneous – early detection.Either end resection.Entire bone excision.L...
Subtotal resection of scapulaSubtotal resection of scapulaTumors of scapular body wihoutjoint involvement is rare.E.g. E...
Partial resection of scapulaPartial resection of scapulaParts of scapula to entire bone.E.g. Benign tumors, TB, chronico...
Resection of proximal humerus:Resection of proximal humerus:Biopsy - Anterior third of deltoid- nocontamination of delto-...
Reconstructive alternatives:Reconstructive alternatives:1. Flial shoulder2. Passive Spacer – Allograft orautograft, fibula...
Allograftarthrodesis is themost stablereconstuction foryoung pts. Withvigorous activities.
Resection of distal humerusResection of distal humerus Lesions in elbow requiring limb salvageare rare. Occasional malig...
Resection of proximal radius / ulnaResection of proximal radius / ulnaConsiderable portion can beresected without reconst...
Resection of distal radius:Resection of distal radius:E.g. GCTReconstruction by:– Arthroplasty,– Arthrodesis using allog...
Resection of distal ulnaResection of distal ulnaNo reconstruction needed.Periosteum is excised with thetumor.
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Limb salvage
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Limb salvage

  1. 1. LIMB SALVAGE SURGERYLIMB SALVAGE SURGERY
  2. 2. Limb SalvageLimb Salvage TRAUMA  TUMOR
  3. 3. 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.
  4. 4. 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
  5. 5. Mangled Extremity Severity ScoreMangled Extremity Severity Score
  6. 6. 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.
  7. 7. 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.
  8. 8. 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.
  9. 9. 2. Proximal arterial infusion withHeparin – Tolazoline – SalineSolution (1000 U heparin + 500mgtolazoline in 1000ml saline) @ 30ml/hr.3. Venous infusion withL.M.W.Dextran @ 500ml/ 12hrs.
  10. 10. TUMOR AND LIMB SALVAGETUMOR AND LIMB SALVAGE
  11. 11. Tumor and limb salvageTumor and limb salvageAdvances in imaging, chemotherapy,radiotherapy & surgical techniqueTreatment of choice in most boneand soft tissue sarcomas– Preoperative radiation – soft tissuesarcomas– Neoadjuvant chemotherapy – bonesarcomas
  12. 12. Rarely L. S. not possible e.g.Rarely L. S. not possible e.g.Neurovascular structuresinvolvement,Displaced pathological fracture,Complications sec to poorlyperformed biopsy.
  13. 13. Limb salvage / AmputationLimb salvage / AmputationExpectations & desires of theindividual and his family.Simon – 4 Issues– Survival (Mortality)– Morbidity – short & long term– Function – compared to prosthesis– Psychosocial consequences
  14. 14. LiteratureLiteratureSeveral studies of comparison of– Multimodal treatment (Sx + CT)– Amputation– DisarticulationOsteosarcoma– Long term survival 20% to 70%– Local recurrence distal femur lesions 5 –10% equivalent to transfemoralamputations.– Very low in hip disarticulation.
  15. 15. Survival - No study has proved anysuperiority of any surgical techniquecomparing– Limb salvage– Transfemoral amputation or– Hip disarticulationProvided wide surgical marginsobtained.
  16. 16. AmputationAmputationTechnically demanding formalignancy– Non standard flaps– Bone graft augmentation – better fxnallimbComplications– Infection, wound dehiscence– Chronic painful limb, phantom limb– Appositional bone growth – revision.
  17. 17. Limb salvageLimb salvageGreater perioperative and long termmorbidity.– More extensive surgical procedure.– Greater risk of infection & wounddehiscence,– Flap necrosis– Blood loss– DVT
  18. 18. Long term complications– Periprosthetic fractures– Prosthetic loosening or dislocation– Non-union of graft-host junction– Allograft #– LLD & late infectionMultiple future operations.1/3rdof long term survivors –amputations.
  19. 19. 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.
  20. 20. 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
  21. 21. 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
  22. 22. 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.
  23. 23. 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.
  24. 24. Allograft-prosthetic compositeAllograft-prosthetic compositereconstructionreconstructionLocation is important.Proximal reconstruction generallyoutlast more distal ones ( Inverse ofprognosis).Prox. femoral > distal femoral > proxtibial.
  25. 25. Leg length discrepancyLeg length discrepancyFuture LLD– Expandable prosthesis– Limb lengthening proceduresComplication may out weigh benefitsesp. in children <10 yrs.– Temporary osteoarticular allograft – tospare the adjacent physis.– Disarticulation and rotationplasty.
  26. 26. Psychological outcomePsychological outcomeNo evidence of any significant diff.Pt must make the final decision– Short & long term goals– Lifestyle modifications.
  27. 27. Margins of tumorMargins of tumor Oncological surgicalprocedures,– margins should bedefined– Amputation /Resection.
  28. 28. Orthopedic oncologyOrthopedic oncologyFour terms1.Intralesional2.Marginal3.Wide4.Radical
  29. 29. Intralesional marginsIntralesional margins Plane of dissectionis within the tumor, Gross residualtumor Symptomaticbenign lesions Debulking Palliativeprocedure inmetastatic disease.
  30. 30. Marginal marginMarginal marginClosest plane of dissection passesthrough the pseudocapsule.Most benign lesionsSome low grade malignanciesSelective high grade malignancies+ preop. radiotherapy and neoadjuvantchemotherapy
  31. 31. Pseudocapsule– containsmicroscopic fociof disease /“satellite” lesions.– Local recurranceif not respondingto C.T. / R.T.
  32. 32. Wide marginsWide marginsPlane of dissection isin normal tissueNo specific distancedefined.Cuff of normal tissueGoal of mostprocedures for highgrade malignancies.
  33. 33. Radical marginsRadical marginsAll 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. *
  34. 34. Oncological standpoint of view:Oncological standpoint of view:8 different surgical procedures– Resection - with 4 types of margins– Amputations - with 4 types of marginsAmputations being usually– wide or radical (high A K amputations)– or may be marginal (Hemipelvectomy).
  35. 35. RESECTION & RECONSTRUCTIONRESECTION & RECONSTRUCTIONCurrent 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.
  36. 36. 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.
  37. 37. ComplicationsComplicationsOncological 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.
  38. 38. 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.
  39. 39. 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.
  40. 40. 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.
  41. 41. 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.
  42. 42. SURGICAL TECHNIQUESURGICAL TECHNIQUEUpper ExtremityLower Extremity &Pelvis
  43. 43. 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.
  44. 44. Resection of shoulder girdleResection of shoulder girdleScapular tumors-– extend to glenohumeral jt.– Extra-articular resection of humeralhead en bloc with scapulaProximal humeral tumors-– Extend into the joint through bicepstendon– Extra-articular partial scapulectomy
  45. 45. 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.
  46. 46. TYPE V –Extra-articular humeralhead resection.TYPE VI - Extra-articular humeraland total scapular resection.Subtypes:– A - Abductor mech. intact.– B - Partial or complete resection.
  47. 47. Tikhoff- Linberg procedure:Tikhoff- Linberg procedure:Total scapulectomyPartial/complete excision of clavicleExcision of prox. humerus.Use:– Malignant tumors about shoulder joint.– Usually sacrificing Axillary N. andsometimes Radial N.
  48. 48. 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.
  49. 49. Subtotal resection of scapulaSubtotal resection of scapulaTumors of scapular body wihoutjoint involvement is rare.E.g. Extraabdominal desmoids, GCT,Low grade Chondrosarcoma – PartialscapulectomySubscapularis m. good marginprevents chest wall invasion.
  50. 50. Partial resection of scapulaPartial resection of scapulaParts 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.
  51. 51. 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.
  52. 52. 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
  53. 53. Allograftarthrodesis is themost stablereconstuction foryoung pts. Withvigorous activities.
  54. 54. 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
  55. 55. Resection of proximal radius / ulnaResection of proximal radius / ulnaConsiderable portion can beresected without reconstruction inradius.
  56. 56. Resection of distal radius:Resection of distal radius:E.g. GCTReconstruction by:– Arthroplasty,– Arthrodesis using allograft or auto graft.Proximal fibular auto graftreconstruction arthroplasty– Maintain motion but light activities.Arthrodesis– Sacrifice motion but more stable.
  57. 57. Resection of distal ulnaResection of distal ulnaNo reconstruction needed.Periosteum is excised with thetumor.
  58. 58. Thank You !
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