Orthopaedics

1. BY :
DR.SURYAMANIKANTA

2.  Surgery is the mainstay in the treatment of
Osteosarcoma.
 Pre op and post operative chemotherapy has
role in treatment of High Grade
Osteosarcoma.
 Osteosarcoma is relatively radioresistant.

3.  surgical excision of the tumor remains a most
essential component of osteosarcoma
management.
 The survival of patients is not affected by
the choice of limb salvage as the surgical
treatment as against amputation.
 This has led to a protocol of considering
every patient for limb salvage surgery at all
specialized centers

4.  Limb salvage should be considered in a
patient only
- if the surgeon is reasonably confident that
surgical excision of the tumor with wide
margins is feasible, and
- expected function of the limb after limb
salvage surgery will be better than ablative
surgery in the form of amputation/
disarticulation.

5.  Limb salvage surgery is contraindicated if
- there is pancompartmental disease with
fungation,
- gross infection,
- encasement of major neurovascular bundle,
- displaced pathological fracture not healing
on neoadjuvant chemotherapy.

6.  On functional and cost of treatment
parameters, limb salvage surgery scores
above amputation.
 Surprisingly, however, the long term
psychological outcome of patients with limb
salvage surgery is reported to be the same as
amputation.

7.  For low grade osteosarcomas (whether
juxtacortical or central) , wide surgical
excision needs to be done as the only
treatment.
 For high grade osteosarcomas, however,
surgery has to be combined with multiagent
chemotherapy.

8.  Surgical margins are defined as intralesional,
marginal, wide, and radical.
 An intralesional margin is created if the
tumor is entered at any point during surgery.
 A marginal margin is created when the
dissection extends into or through the
reactive zone that surrounds the
tumor.

9.  A wide margin is created when the reactive
zone is not entered and the entire dissection
is performed through healthy tissues.
 A radical margin is created when the entire
bony or myofascial compartment or
compartments containing the tumor is
resected

10.  The principle of surgical resection of
osteosarcoma (as for any sarcoma of bone)
is resection with wide margins.
 This usually means removal of 2 cm normal
tissue or a good anatomical barrier (e.g.
fascial layer/articular cartilage) and
osteotomy of bone 3-5 cm away from the
level of involvement.

11.  Joint sparing resections using the open
physeal cartilage as margin are also
oncologically sound, while saving the nearby
joint at the same time.
 Similarly, distraction of growth plate is also
being done preoperatively to enable
preservation of the physis while retaining
good margins of excision.

12.  Reconstruction of large segmental defects
following resection is a challenging task.
 An ideal reconstruction should be
- durable,
- compensate for the loss of growth of the
involved limb in skeletally immature patients,
- result in the function and appearance of the
limb as close to normal as possible,
- be compatible with early rehabilitation, and
- be cost effective and readily available.

13.  Reconstruction with megaprosthesis is a
common mode of reconstruction as it has a -
- predictable functional outcome,
- allows early rehabilitation,
- allows for intraoperative flexibility in the
length of the reconstruction required and
- being non biological, is unaffected by
adjuvant chemotherapy.

14.  Disadvantages : vulnerability to wear and
tear leading to loosening/ breakage in the
long term.
 The reattachment of tendons to the
prosthesis is another factor compromising
the functional outcome .

16.  Biological reconstruction may be used for
arthrodesis, intercalary reconstruction, or
osteoarticular graft.
 They depend on bone healing for
rehabilitation, which is subject to effects of
adjuvant therapy and is associated with a
long rehabilitation time.

17.  Osteoarticular allografts offer the advantage
of good reattachment of tendons for optimal
function, particularly at sites such as
proximal tibia, proximal femur and proximal
humerus.
 However, the availability of cadaveric grafts
is limited, and the issues of infection, graft
fracture, non union and osteoarthritis are
reasons for concern.

18.  Vascularized autografts are also used for
intercalary defects, arthrodesis, or as
growing osteoarticular grafts. They unite
more predictably and show earlier
hypertrophy compared to nonvascular
autografts.

19.  Periprosthetic infections are a frequent
(approximately 10%) complication of limb
salvage surgery which is largely due to
prolonged and repeated surgeries, as well as to
the immunocompromised condition of these
patients.
 The highest risk of infection has been observed
after proximal tibia resection due to the poor
soft tissue coverage and pelvic resection due to
dead space and vicinity to pelvic viscera.
 Radiation therapy and expandable prosthesis are
reported to be risk factors.

20.  Usually one or more attempts at
debridement with antibiotic therapy
(systemic and local antibiotic cement beads)
are indicated as first line treatment of
infection of tumor megaprosthesis,
particularly in the early postoperative
setting.
 If these measures don’t work, implant
removal and thorough debridement and
lavage is indicated.
 Usually an antibiotic impregnated cement
spacer is placed before a new implant is
inserted as a two staged procedure.

21.  Occurs in about 5% of patients undergoing limb
salvage surgery for extremity and girdle
osteosarcomas at specialized centers.
 The treatment depends on the timing of
recurrence, association with distant
metastases, and resectability.
 Resectability is decided on the same criteria as
a primary tumor, and local recurrence does not
always warrant an amputation.
 A short disease free survival or an association
with pulmonary metastases may warrant first or
second line chemotherapy.

22.  Mechanical failure is the commonest reason
for failure of reconstruction with
megaprosthesis.
 Methods to improve the longevity of tumor
megaprosthesis, and improvements in
prosthetic technology like rotating platform
design, HA coated collar and stem, porous
tantalum and compression osteointegration
technology hold promise in overcoming
these limitations.

23.  4. Non union:
 The effect of adjuvant chemotherapy/radiotherapy,
and use of nonvascular bone (e.g. allograft
/extracorporeally treated bone) leads to a greater
incidence of these complications.
 5. Metastatic disease :
 Generally carries a poor prognosis. The treatment
has to be individualized to the patient, depending
on the site (pulmonary or extrapulmonary),number
and time of presentation.

24.  Surgical management of patients with
osteosarcoma is challenging.
 No difference in survival has been shown
between amputations and adequately
performed limb-salvaging procedures.
 Optimal tumor resection and a functional
residual limb with increased survival of both
the patient and the reconstruction are the
goals of today’s orthopedic oncology.

25.  Removal of tumor with adequate margins
should be the primary consideration,
whether the surgery is limb sparing or limb
sacrificing.
 Reconstruction should be individualized to
the needs of the patient keeping in mind the
oncological, functional and social
requirements.

26.  It should be noted that reconstruction of
large bone defects is not the only goal.
 Patients with osteosarcoma have a
compromised healing response, and require
modalites that trigger bone repair to limit
the chance of nonunion.

27.  Tissue engineered grafts with
bisphosphonates, statins,
nanohydroxyapatite, BMPs, or strontium,
which have osteoinductive properties, are
being developed to accelerate calcium
deposition and new bone formation and to
inhibit osteoclastic reaction.
 Growth factors, vitamins, and GAGs also
have properties affecting bone healing.

28.  Tissue engineering and regenerative
medicine (TERM) approaches four main
categories: scaffolds, therapeutic agents,
stem cells, and gene therapy.
 TERM attempts to design a more suitable
treatment strategy. Tissue scaffolds are a
newer solution for reconstruction.

29.  Immunotherapy, chemoimmunotherapy and
radioimmunotherapy are future options in
managing osteosarcoma

30.  Rotationplasty is an option for the young child
who is skeletally immature and in whom the
tumor involves the distal femur or proximal
tibia.
 This procedure involves intercalary resection of
the tumor about the knee and 180° rotation of
the distal leg, creating a new knee joint from
the prior ankle joint, enabling active knee
motion.
 Rotationplasty is done with all autologous tissue,
which may lead to decreased postoperative
infection and mechanical problems.

31.  Oncologically Above Knee but functionally
below knee amputation
 Definitive surgery – High durability
 Low complication rate
 Maintenance of growth
 High level of function
 Near normal function

32.  Poor cosmesis
 Psychological issues
 Prosthesis issues
 Complications – Non union

33.  Stages IIA-IVB (high grade):
 Chemotherapy is warranted for all stages of
high-grade osteogenic sarcomas
 For nonmetastatic osteosarcoma, 2-3 cycles
of chemotherapy are typically given
preoperatively; 3-4 cycles of chemotherapy
are given postoperatively.

34.  Eliminates micro and macro metastasis
 Reduces tumor size and vascularity
 Widens tumor free surgical margin
 Prevents intra op spillage
 Facilitates elective placement of
Endoprosthesis
 Helps in healing of pathological fractures
 Prevents or reduces local recurrence
 Prognostic factor

35.  First-line treatment recommendations
 First-line treatment consists of any one of
the regimens listed below, including the
following
 Doxorubicin and cisplatin
 High-dose methotrexate, cisplatin, and
doxorubicin (MAP)
 Ifosfamide and etoposide
 Ifosfamide, cisplatin, and epirubicin

36.  MAP:
 Neoadjuvant setting:
 High-dose methotrexate 8-12 g/m2 IV
 cisplatin 60 mg/m2 IV plus
 doxorubicin 37.5 mg/m2/day IV

37.  Mucositis
 Cardiomyopathy (doxorubicin)
 Alopecia
 Myelosupression
 Nausea/vomiting
 Relative immunocompromise
 Sepsis
 Rarely death
 Neuro and neprotoxicity - cisplatin

38.  Granulocyte Colony-stimulating factor(G-CSF) :
Improves neutropenia by stimulating neutrophil
production by marrow thereby decreasing
infections.
 Erythropoietin – Stimulates RBC production.
 Dexrazoxane – protects against cardiomyopathy
of Doxorubicin.
 Leucovirin rescues normal cells from effects of
high dose methotrexate and decreases
myelosupression and mucositis.

39.  Medicines that target specific molecules on the
cancer cells. These are known as targeted
therapies
 Some of these are man-made versions of immune
system proteins, known as monoclonal
antibodies.
 These antibodies attach to certain proteins on
the cancer cell and help to stop the growth or
kill the cancer cells.
 Examples now being studied include antibodies
against the insulin-like growth factor receptor 1
(IGF-1R), a protein that may help cancer cells
grow.

40.  Drugs that affect a tumor’s ability to make
new blood vessels, such as sorafenib
and pazopanib
 Drugs that target the mTOR protein, such
as temsirolimus and everolimus

41.  Clinical trials are looking into ways to help
the patient’s own immune system recognize
and attack the osteosarcoma cells.
 An experimental immune-modulating drug
called muramyl tripeptide (also known as
MTP or mifamurtide) has been shown to help
some patients when added to chemotherapy

42.  Interferon-g is able to sensitize osteosarcoma
cell lines to chemotherapeutic drugs, and it
plays an important role in angiogenesis.
 Additionally, it has been demonstrated that
interferon alpha (IFN-a) can suppress human
osteosarcoma cell invasion and enhance
cisplatin-mediated apoptosis and autophagy

43.  Bisphosphonates are a group of drugs that
targets osteoclasts and are used in certain
cancers that have spread to the bone.
 Some of these drugs, such as pamidronate
and zoledronic acid, are now being studied
for use in osteosarcoma as well.
 Another drug that affects bones, known
as saracatinib, is also being studied.

44.  It has been shown that combined therapy
using zoledronic acid and radiation or multi-
agent chemotherapy against osteosarcoma
cell lines is effective and promising with
fewer side effects compared with their use
individually

45.  Mainly for palliation
 Used following intial resection with positive
margins.
 It helps in treatment of unresectable tumors
and releiving the symptoms

49.  Bone metastases in pts with Osteosarcoma
are unusual and normally appear late in
course of disease.
 It is difficult to explain how the tumor cells
disseminated in cases of bony metastases
without pulmonary involvement, as the lungs
should act as a filter in the haematogenous
dissemination of the tumor.

50.  Diagnosis by clinical symptoms, imaging
studies and a biopsy.
 First symptom is pain mainly in the night,
similar to that with the primary tumor.
 Special imaging studies should be undertaken
when there are symtoms such as unexplained
pain, inflammatory pain, or neurological
symptoms presenting severeal years after
completion of treatment.

51.  It has to be confirmed by means of biopsy.
 Bone necrosis, traumatic or stress lesions or
other benign conditions can simulate bony
metastases.

55.  When solitary metastases are detected
treatment is similar as that of primary lesion,
including neoadjuvant chemotherapy and
surgery
 The nature of surgical procedure depends on
the site of the lesion

56.  For a metastasis in the Knee – wide resection
and reconstruction with composite allograft
prosthesis
 For distal Contralateral Femur – marginal
resection and reconstruction with intercalary
allograft, to preserve knee

57.  Metastasis in Acetabulum – marginal
resection without reconstruction
 For mets in Lumar spine – Intralesional
resection and spinal fusion.

60. HAVE A NICE DAY