Limb salvage of lower extremity

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Tumor, limb salvage, hip and knee

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Limb salvage of lower extremity

  1. 1. RECONSTRUCTIVE SURGERIES OFRECONSTRUCTIVE SURGERIES OF TUMORS AROUND HIP AND KNEE JOINTTUMORS AROUND HIP AND KNEE JOINT (LIMB SALVAGE SURGERIES)(LIMB SALVAGE SURGERIES) Dr. Sushil Paudel
  2. 2. History of limb salvage surgeryHistory of limb salvage surgery  Lexer – 1st successful series of 6 pts.  Concept of using allografts in tumor surgery – Lexer 1907  Barggreve : First described rotationplasty in 1930 for TB of limbs  Kristen Knahr and Salzer in 1975 used rotationplasty in osteosarcoma of distal femur
  3. 3. Definition of limb salvage surgeryDefinition of limb salvage surgery A set of surgical techniques that have been developed to restore the skeletal continuity following the enbloc resection of bone and soft tissue neoplasm Goal of limb salvage surgery : Painless limb Functional, tumor free limb
  4. 4. Why limb salvage surgery ?Why limb salvage surgery ? Before 1970: 5 years survival → 10-20% in osteosarcoma and Ewing sarcoma. Now 5 years survival → 65-75% Limb salvage surgery possible → 90% cases Reasons: Chemotherapy Better diagnostic facilities Improved and well defined Surgical technique {OCNA 1991}
  5. 5. Preoperative evaluationPreoperative evaluation Biopsy : first step in reconstructive surgeries Type of biopsy : Core biopsy (Preferred) Open biopsy: Incisional (Preferred) Excisional Site : Proximal femur : Lateral approach Distal femur: Anterior approach Lateral approach Proximal tibia: Medial at flare of metaphysis
  6. 6. Biopsy
  7. 7. Principles of biopsyPrinciples of biopsy Longitudinal incision Violate only one compartment Muscles are split Done by same surgeon in same institute Avoid joint contamination Soft tissue element best for biopsy.
  8. 8. Osteosarcoma
  9. 9. Plain X-ray Affected bone and joint Chest X-ray Skeletal survey MRI: Investigation of choice Soft tissue extent Skip lesion Vascularity of tumor Neurovascular involvement Radiological investigations
  10. 10. CT Scan Cortical involvement Soft tissue calcification CT chest: Metastasis Bone Scan Tc99 - metastasis Angiography (DSA) Vascularity of the tumor ,donor and recipient site in microvascular reconstructive surgery Radiological investigations(contd..)
  11. 11. MRI DSA
  12. 12. Staging of tumorStaging of tumor Enneking system : Benign tumor : Latent Active Aggressive Malignant tumor Stage Grade Site Metastasis IA G1 T1 M0 IB G1 T2 M0 IIA G2 T1 M0 IIB G2 T2 M0 III G1-2 T2 M1
  13. 13. AJCC system :AJCC system :  Tumor size  Grade  Depth  Metastasis Low grade  Well differentiated (metastasis <25%)  Few mitosis  Moderately cytological atypia High grade  Poorly differentiated  High mitotic stage  High cell/matrix ratio.
  14. 14. Psychosocial andPsychosocial and functional evaluationfunctional evaluation Musculoskeletal tumor society functional score. • Pain, function, acceptance,gait. Short form 36. Toronto extremity salvage score.
  15. 15. Role of chemotherapy andRole of chemotherapy and radiotherapyradiotherapy  Neoadjuvant  Adjuvant  Indication : High grade tumor Low grade tumor  Advantages of neoadjuvant chemotherapy Prevent development of drug resistance Prevent micrometastasis Reduce size of tumor Measure effectiveness of chemotherapy Allow planning of surgery and procurement of implant
  16. 16. Regimen of chemotherapy of osteosarcoma:Regimen of chemotherapy of osteosarcoma: AIIMS ProtocolAIIMS Protocol Multiagent neoadjuvant chemotherapy: 1. CAMP regimen ↓ 3 cycles at 3 week interval 2. ICE regimen ↓ 3. High dose methotrexate Follow up:  HPE > 90% necrosis  Clinical and radiological re-evaluation after chemotherapy ↓ Operate after 12-13 week ↓ Wound healing for 3 weeks ↓ Continue adjuvant chemotherapy 3 weekly x 40 weeks
  17. 17. T10 regime : (Sloan Ketring cancer centre)  Combination of - high dose methotrexate, leucovorin, CDDP, BCD. Radiotherapy : Osteosarcoma - No definitive role Ewing sarcoma  Chemotherapy: Vincristine, cyclophosphamide, actinomycin, ifosfamide.  Radiotherapy : 30-40G to whole bone and Booster to primary tumor with two doses of 50-55G.  Chemotherapy plus Radiotherapy
  18. 18. Surgical margin
  19. 19. Limb salvageLimb salvage Combines two procedures-  Wide resection  Reconstruction of skeletal defect Survival and local recurrence depends on margins achieved during resection and not on method of reconstruction
  20. 20. IndicationIndication  Every patient with tumor of the extremity should be considered for limb salvage if the tumor can be removed with an adequate margin and the resulting limb is worth saving  No justification for limiting the limb salvage process based only on the prognosis
  21. 21. Salvaged limbSalvaged limb  Acceptable degree of function  Cosmetic appearance  Minimal amount of pain  Durable enough to withstand the demands of normal daily activities
  22. 22. ContraindicationsContraindications  Neurovascular involvement  Large size tumour  Displaced pathologic fracture(relative contraindication)  Fungating and infected tumors  Recurrence of malignant tumors  Skeletal immaturity - 60% growth occur through distal femoral and proximal tibial epiphysis Pulmonary metastasis is not a contraindication of surgery Contraindications of limb salvage are the indications for amputation
  23. 23. ContraindicationsContraindications Three strike rule  Bone  Nerves  Vessels  Soft tissue envelope If three of these key components are involved, the limb salvage is probably not worth considering
  24. 24. Principles & TechniquesPrinciples & Techniques Resection of tumor – Principles of surgical oncology Skeletal reconstruction – Principles of orthopaedic surgery Soft tissue & muscle transfer – Principles of plastic surgery
  25. 25. Resection of tumor : Intra articular Extra articular Margin → 5-7 cm * Adherent neurovascular bundles - amputation Surgical margin - near neurovascular bundle (* OCNA JAN 91)
  26. 26. KNEE
  27. 27. Methods of ReconstructionMethods of Reconstruction  Arthrodesis  Mobile joint reconstruction − Osteoarticular allograft − Endoprosthetic replacement − Allograft Endoprosthetic composite − Rotationplasty − Autoclaved tumor bone
  28. 28. Arthrodesis of hipArthrodesis of hip Advantage :  Physically active life Failure are less Disadvantage : Loss of motion : no functional limitation Difficult to position the extremity for arthrodesis Long healing time
  29. 29. Arthrodesis of hip (contd.) Technique : Fusion of proximal femur to ilium / ischial tuberosity with or without intercalary graft If gap <6-8 cm: No intercalary allograft >6-8 : allograft ↓ Allograft with head : Fixed with long screw to pelvis and to femur - cobraplate / DCP Postoperative : Hip spica
  30. 30. ARTHRODESIS OF HIP
  31. 31. Arthrodesis of kneeArthrodesis of knee Young adult patient Knee arthrodesis using regional autograft Enneking and Shirley Dual fibular graft Using allograft+ intramedullary nail Using intercalary allograft with plate and screw  PostoperativePostoperative
  32. 32. TURN O PLASTY
  33. 33. TURN O PLASTY
  34. 34. RECONSTRUCTION USING BONE GRAFT Non-articular (Intercalary) Articular reconstruction Autograft Allograft
  35. 35. Non-articular(Autogenous) graft Advantage : Hypertrophy and no immune rejection Disadvantage : Limited source and donor site morbidity • Sources : Fibula, Iliac crest and tibia  Enneking - Compensatory hypertrophy 32% In fibular graft (Atrophy 9%)  Zwierzchowski - Ideal for children (OCNA JAN 91)
  36. 36. Non-articular(Autogenous) graft Vascularized fibular graft : Advantage: No creeping substitution Heal in hostile environment (Irradiated tissue and active infection) Healing within 6 months Disadvantage : Technically demanding Long operative time
  37. 37. Osteoarticular graft (Allograft) : To restore anatomy and physiology of near normal joint Advantages : Length can be adjusted Biological soft tissue healing Avoid the risks and complications of intramedullary fixation of endoprosthesis Direct attachment of remaining musculature
  38. 38. Disadvantage Long healing times Potential for transfer of disease and infection Immune rejection Necessity of articular surface size matching Fracture Infection Non union Osteoarticular graft (Allograft)(contd.) :
  39. 39. Technique  Size Trial for reduction : should produce suction when being dislocated - negative – alloendoprosthesis Fixation with plate on anterolateral surface Abductor attached to graft Postoperative Restrained exercise - 6 weeks Strengthening exercise - 8 weeks Weight bearing - 12 months
  40. 40. Osteoarticular graft (distal femur) Large graft Rigid fixation to host bone with plate on lateral and anterior surface of femur (entire length) Reconstruction of posterior capsule, collateral and cruciate ligaments with nonabsorbable suture (heavy) Unicondylar arthroplasty : Stage 3 or IA • Patella graft • Vascularized fibula Postoperative : Full weight bearing after one year
  41. 41. Reconstructions using autoclavedReconstructions using autoclaved bone graftbone graft
  42. 42. Proximal tibialProximal tibial Limb salvage is difficult Proximity to knee joint Poster lateral position of neurovascular bundles Lack of Adequate soft tissue Difficulty of reattachment of patellar tendon after resection - principle challenge
  43. 43. Proximal femoral endoprosthesis Oldest, widely used method Treatment of choiceTreatment of choice of patient with limited life expectancy
  44. 44. Type of endoprosthesis Bipolar THR: Short stem  Long stem
  45. 45. Proximal femoral endoprosthesis Advantage No prolong protected weight bearing Good ambulatory gait No risk of transmission of disease / infection Disadvantage Mechanical failure Loosening Stress fracture
  46. 46. Proximal femoral endoprosthesis 14-18 mm diameter : Age, Size of patient and Diameter of femur Length 135-200mm Anterior bow Modular prosthesis : Extramedullary porous in growth material on the segment proximal to stem. Trial in reduction
  47. 47. Postoperative Hip spica Instability during surgery : Abduction brace : 2-3 months
  48. 48. Proximal femoral replacement – problems  Instability  Dislocation – 2% - 14%  Loosening of acetabular component -46%  Aseptic loosening of femoral component  Functional outcome limited due to poor abductor function  Infection 0-14% Yavuz kabuet et al CORR 91 Seminar on surgical oncology (1997)13:3-10
  49. 49. Segmental custom made total knee replacement Indications Primary malignant tumor Metastatic tumor Stage three begin tumor
  50. 50. MODULAR CUSTOM MADE KNEE JOINT
  51. 51. Segmental custom made total knee replacement Advantage Immediate stability Early mobilization and weight bearing Disadvantage Mechanical failure Stress fracture Failure of fixation to host bone Limited ability to change the size intraoperatively Time delay in the procurement of implant Expensive
  52. 52. Prosthesis Rotating hinge knee Flexion and extension and axial rotation Size and length Femoral stem 130-155mm Postoperative Flexion - 90° and full extension 6 month - normal gait without aid
  53. 53. Distal femoral prosthetic replacement  Overall survival 5yrs - 80% 10yrs - 65% 20yrs - 53% Unwin et al:J.Arthroplasty:8:259-68 (1993)  Rotating hinge prosthesis -90% 5 yrs.survival
  54. 54. Proximal tibial prosthetic replacementProximal tibial prosthetic replacement  Limitations due to poor native soft tissue coverage  Unreliable option for ext.mechanism reconstruction  5 yrs. survival - 45%-74%  10 yrs.survival - 45%-53%  Infection upto 31%  Wound complication upto 38% Malawer et al-J.B.J.S.(A) 77A:1154-1165.1995
  55. 55. Alloprosthesis  Endoprosthesis fixed to a allograft rigidly fixed with host bone HIP: Indication: If allograft does not fit into acetabulum Inadequate acetabular articular cartilage KNEE: Indication : Removal of most or all ligamentous structure around knee Proximal tibia resected with distal femur but extensor mechanism saved
  56. 56. Younger patientsYounger patients Rotation plasty : Act like a below knee amputation Expandable prosthesis Arthrodesis of hip
  57. 57. Rotation plasty Borggreve : First described in 1930 for TB of limbs Kristen : Knahr and Salzer in 1975 used in osteosarcoma of distal femur <10 year with removal of distal femoral epiphysis with tumor Sciatic nerve to be preserved Winkelmann classified rotation plasty in five groups • Group AI : Lesion in distal femur • Group AII : Lesion in proximal tibia
  58. 58. ROTATIONPLASTY AII BI BII BIII AI
  59. 59. Rotation plasty Group BI : Lesion in the proximal femur sparing the hip joint and gluteal muscles Group BII : Lesion in proximal femur with involvement of hip joint and adjacent soft tissue Group BIII: Lesion mid femur Postoperative : Single hip spica
  60. 60. Expandable prosthesis : Hollow titanium tube assembled over a threaded shaft and fitted with a adjustable ring. Lengthening : -1 to 2 cm at a time
  61. 61. Soft tissue reconstruction HIP- Capsule Abductor Reattatched to endoprosthesis or allograft Not possible : Advancement of tensor fascia lata and Anterior attachment of iliopsoas to endoprosthesis. If abductor : can not restored - Arthrodesis of hip Muscle flap: Sartorius / Rectus femoris
  62. 62. Extensor mechanism KNEE JOINT Patellar tendon reattachment Pes anserinus / semimembranosus Soft tissue reconstruction Medial gastrocnemius flap Advantage : • Cover the prosthesis • Suturing of patellar tendon and capsule to muscle Disadvantage : • Bulk of leg increases • Split thickness graft • Rehabilitation only after 3-4 week • Extension lag 70-90°
  63. 63. Outcome after limb salvage surgeryOutcome after limb salvage surgery No difference in psychological,physical function, survival, disease free interval. Irwin et al: JBJS 72A;90 A/k amputation Disarticulation Limb salvage Local recurrence 9% - 8% Reoperation 10% 2% 30% Functional score 19% 16% 23% Bruce T. Rougraft et al: JBJS 1994 surgery
  64. 64. ConclusionConclusion  Limb salvage has become accepted standard care of the pt’s with malignant bone tumors  Success depends on prompt detection and early referral by primary care doctor and on careful and coordinated sequences of events  Achieving a surgical margin that will ensure a low rate of local recurrence is paramount  A variety of techniques are available
  65. 65. KEEP CONFERENCE HALL CLEAN PLEASE DISPOSE EMPTY BOXES OUTSIDE THE HALL

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