Limb salvage of lower extremity


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Tumor, limb salvage, hip and knee

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Limb salvage of lower extremity

  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
  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
  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
  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