Limb salvage

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Various Methods of Limb Salvage in Orthopaedics

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  • 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.
  • Limb salvage

    1. 1. Department of Orthopaedics MH Kirkee SEMINAR LIMB SALVAGE Maj Rohit Vikas Resident
    2. 2. LIMB SALVAGE INTRODUCTION
    3. 3. 1970s amputation wasstandard treatment
    4. 4. LIMB SALVAGE PRINCIPLES
    5. 5. COMPARED WITH AMPUTATION AND PROSTHETIC REHABILITATION SURVIVAL RECURRENCE Oscar Pistorius FUNCTION DURABILITY COMPLICATIONS NEOADJUVANT CHEMOTHERAPY
    6. 6. CONTRAINDICATIONS BARRIERS TO LIMB SALVAGERelative Contraindications to Limb-Sparing ProceduresMajor neurovascular structures encased by tumor when vascular bypass is not feasiblePathologic fracture with hematoma violating compartment boundaryInappropriately performed biopsy or biopsy-site complicationsSevere infection in the surgical fieldImmature skeletal age with predicted leg-length discrepancy >8 cmExtensive muscle or soft-tissue involvementPoor response to preoperative chemotherapy
    7. 7. Clinical EvaluationPre Op StagingBiopsy PrinciplesNeoadjuvant ChemotherapyTumour 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 SectionSkeletal ReconstructionReconstruction of Soft Tissue and Wound CoverPost op Chemotherapy
    8. 8. LIMB SALVAGERESECTION ARTHRODESIS
    9. 9. EXTERNAL FIXATOR INTRAMEDULLARY NAIL BONE GRAFTS INTERNAL FIXATIONDual fibular autografts
    10. 10. Chondrosarcoma, primary central -Distal femur
    11. 11. LIMB SALVAGERESECTION + RECONSTRUCTION AUTOGRAFT
    12. 12. LIMB SALVAGERESECTION + RECONSTRUCTION BONE CEMENT
    13. 13. LIMB SALVAGERESECTION + RECONSTRUCTION ALLOGRAFT
    14. 14. 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
    15. 15. Osteoid Osteoma +Osteogenic sarcoma, intracortical - Femur
    16. 16. osteoid-forming tumor being produced byosteoblastic cells with a low mitotic indexwithout an aggressive pattern. This iscompatible with the diagnosis of osteoidosteoma
    17. 17. Painful recurrence with a lytic area twiceas large as the original nidus.
    18. 18. A neoplastic osteoid formationby osteoblastic cells that havethe appearance of an low gradeosteosarcoma.
    19. 19. Cortical allograft in position followingresection of 70% of the diaphysis of thefemur with a side plate for stability.
    20. 20. Osteogenic sarcoma, intracortical -Distal humerus
    21. 21. 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.ADVANTAGESAvailability in all sizes and shapesProgressive incorporation into host boneConventional arthroplasty instead of custom madeprosthesisAttachment sites available for resected muscles andjoint stabilisers – better functionNo donor site morbidityFailed allograft – further options available
    22. 22. OSTEOARTICULAR ALLOGRAFT RECONSTRUCTION
    23. 23. GCT – Extended Curettage + PMMA Replaced with a hemicondylarLateral compartment degeneration osteoarticular allograft.
    24. 24. LIMB SALVAGERESECTION + RECONSTRUCTION VASCULARISED BONE GRAFT
    25. 25. GCT
    26. 26. Radiation associated ST # Femur with Nonunion managed with Vascularised fibular Graft
    27. 27. LIMB SALVAGERESECTION + RECONSTRUCTION PROSTHESIS
    28. 28. 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%.
    29. 29. ONCO PROSTHESIS FOR PROXIMAL FEMURFibrosarcoma - Femur
    30. 30. ONCO PROSTHESIS FOR PROXIMAL FEMUR Fibrosarcoma - Femur
    31. 31. ONCO PROSTHESIS FOR PROXIMAL FEMURFibrosarcoma - Femur
    32. 32. ONCO PROSTHESIS FOR PROXIMAL FEMUR Fibrosarcoma - Femur
    33. 33. ONCO PROSTHESIS FOR PROXIMAL FEMUR Fibrosarcoma - Femur
    34. 34. ONCO PROSTHESIS FOR PROXIMAL FEMUR Radiation associated Fracture of Proximal Femur
    35. 35. ONCO PROSTHESIS FOR DISTAL FEMUR Osteosarcoma - Femur
    36. 36. ONCO PROSTHESIS FOR DISTAL FEMUR Osteosarcoma - Femur
    37. 37. ONCO PROSTHESIS FOR DISTAL FEMUR Osteosarcoma - Femur
    38. 38. ONCO PROSTHESIS FOR DISTAL FEMUR Osteosarcoma - Femur
    39. 39. ONCO PROSTHESIS FOR DISTAL FEMUR Osteosarcoma - Femur
    40. 40. ONCO PROSTHESIS FOR DISTAL FEMUR Osteosarcoma - Femur
    41. 41. ONCO PROSTHESIS FOR DISTAL FEMURChondrosarcoma – Dedifferentiated ,Femur
    42. 42. ONCO PROSTHESIS FOR DISTAL FEMUR
    43. 43. ONCO PROSTHESIS FOR DISTAL FEMUR
    44. 44. ONCO PROSTHESIS FOR DISTAL FEMUR
    45. 45. ONCO PROSTHESIS FOR DISTAL FEMURRecalcitrant Non union of Radiation associated Fracture SC Femur
    46. 46. ONCO PROSTHESIS FOR DISTAL FEMUR TMH-NICE (New Indigenous Customised Endoprosthesis)joint
    47. 47. ONCO PROSTHESIS FOR PROXIMAL HUMERUS
    48. 48. Osteosarcoma of scapula. Unconstrained total scapular prosthesis with cemented humeral component used for limb salvage.
    49. 49. SADDLE PROSTHESISMARK II
    50. 50. LIMB SALVAGE RESECTION + RECONSTRUCTIONALLOGRAFT PROSTHESIS COMPOSITE Attachment sites available for resected muscles and joint stabilisers – better function
    51. 51. Combined allograft andcemented Neer prosthesis
    52. 52. Low-grade cartilaginous tumor but with areas in the central portion that show osteoidbeing produced by the tumor as well
    53. 53. Osteogenic sarcoma, periosteal -Proximal tibia
    54. 54. A total knee implant with an allograft placed over theproximal portion of the tibial component and a shortside plate to control rotation of the allograft.
    55. 55. Restoring bone stockPreventing loosening by increasing interfacesurface between prosthesis and boneLimiting proximal bone resorption
    56. 56. LIMB SALVAGERESECTION + RECONSTRUCTION AUTOCLAVED BONE GRAFT +/- PROSTHESIS
    57. 57. Malignant fibrous histiocytoma - Proximalhumerus
    58. 58. Part of the reconstructive procedureconsists of autoclaving the surgicalspecimen at 130 degrees centigradefor 4 min.This kills the tumor but preservesthe physical aspects of thebone, which is then placed backover a long-stem Neer prosthesisand cemented into position.
    59. 59. Acetabulum following the resectionshowing the hyperemic changes in theacetabular synovial tissues, a responseto the antigen stimulation of thenearby tumor in the upper femur.There is no crossover into theacetabular structures preventing theneed for a more aggressive internalhemipelvectomy reconstruction.
    60. 60. Osteogenic sarcoma, classic - Pelvis
    61. 61. 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 patients pelvis for reconstructive purposes.
    62. 62. Pins were placed through the autoclaved autograft along withscrews and plates.A routine total hip prosthesis was cemented into position on Entire acetabulum recemented in anatomical position thattop of the threaded Steinmann pins. allows for excellent weight bearing function
    63. 63. LIMB SALVAGERESECTION + RECONSTRUCTION TOTAL FEMUR
    64. 64. Ewings sarcoma – Femur With Pathological fracture from biopsy site
    65. 65. Custom total femoral implant
    66. 66. LIMB SALVAGERESECTION + RECONSTRUCTION ROTATIONPLASTY
    67. 67. ROTATIONPLASTY• Group AI— Distal Femur.
    68. 68. ROTATIONPLASTY• Group AII—Proximal Tibia.
    69. 69. ROTATIONPLASTY• Group BI— Proximal Femur sparing the hip joint and gluteal muscles.
    70. 70. ROTATIONPLASTY• Group BII— Proximal Femur with involvement of hip joint and contiguous soft tissue.
    71. 71. ROTATIONPLASTY• Group BIII—Lesion in midfemur.
    72. 72. ROTATIONPLASTYBorggreve-Van Nes rotationplasty
    73. 73. ROTATIONPLASTY
    74. 74. ROTATIONPLASTY
    75. 75. ROTATIONPLASTY
    76. 76. ROTATIONPLASTY
    77. 77. Osteogenic sarcoma, classic07y/ M
    78. 78. 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 tissueamputation 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 thepatient with a functional end result similar to a routine supracondylar amputation.Traditional design of the skin flaps for a supracondylar amputation.
    79. 79. The proximal 10 inches of the tibia has been mobilized from its surrounding softtissue, leaving only the anterior compartment and the deep posterior compartmentintact. The popliteal vessels are intact proximally just beneath the tibial plateau, stillsupplying vascular nutrition to the resected tibia.
    80. 80. The surgeon has placed the proximal 10inches of the tibia upside down into thethigh with a sideplate utililizedproximally to fix the distal part of thetibia to the proximal part of the femur.We are looking directly at the tibialplateau surface of the knee joint thatnow acts as the distal end of thefemoral stump to replace the resecteddistal femur.The resected distal femur and its tumorcontent is seen lying next to thewound.
    81. 81. LIMB SALVAGE RESECTION +LIMB LENGTHENING
    82. 82. BONE TRANSPORT
    83. 83. BONE TRANSPORT
    84. 84. LIMB SALVAGECOMPOSITE TISSUE ALLOGRAFT
    85. 85. COMPOSITE TISSUE ALLOGRAFT First hand transplant by Dubernard et al in 1998More than 100 CTA transplantations have been performed since 1998These transplantations have included the upper extremity, laryngeal tissue, abdominalwall, face, bone, joint, uterus, nerve, tongue, and genitals.Still an experimental reconstructive procedure.
    86. 86. COMPOSITE TISSUE ALLOGRAFTSkin - most antigenic and immunoreactive tissue in CTA
    87. 87. COMPOSITE TISSUE ALLOGRAFTIn the United States, 5 hands have been transplanted in five patients since 1999at the University of Louisville3 hands have been transplanted in two patients at the University of PittsburghMedical 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.
    88. 88. LIMB SALVAGE IN CHILDREN
    89. 89. 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).
    90. 90. LIMB SALVAGE IN CHILDRENExpandable prosthesis• Restoration of limb length desirable – Lower limb • Gait abnormalities, leg pain, and back pain – Upper limb • short arm is cosmetically embarrassing
    91. 91. The leg was graduallylengthened byinserting and turningwith a metal key via aone centimetre skinincision.Expandable custom-made tumourprosthesis.
    92. 92. Electromagnetic external drive machine
    93. 93. 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
    94. 94. LIMB SALVAGE RESULTS
    95. 95. 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.
    96. 96. 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)

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