3. Limb salvage and traumaLimb salvage and trauma
ďŹ Starts at E.R. when a mangled
extremity arrives â series of
decisions
1. If life in danger, should the mangled
limb be amputated
2. If stable, should an attempt be made to
salvage the mangled limb
3. If salvage, what is the sequence of
repairs
4. If salvage fails, when should
amputation be performed.
4. Most difficult decisionMost difficult decision
ďŹ Whether to attempt salvage or not
ďŹ 5 Scoring systems published
Author / Year Name Criteria
Gregory et al.1985 Mangled Extremity
Syndrome Index
9
Seiler et al.1986 - 4
Howe et al.1987 Predictive Salvage Index PSI 4
Johansen et al.1990 Mangled Extremity Severity
Score (MESS)- Prospective
4
Russell et al.1991 Limb Salvage Index (LSI) 7
6. Two major criteriaTwo major criteria
ďŹ Immediate amputation Vs attempted
salvage, if either present- amputation
better choice.
1. Loss of arterial inflow
>6 hrs., esp. in
presence of a crush
injury which disrupts
collateral vessels.
2. Disruption of
posterior
tibial nerve.
7. Relative indications of amputation inRelative indications of amputation in
Gustilo 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 for
soft tissue coverage and tibial
reconstruction.
ďIf 2 of these
present
immediate
amputation is
recommended.
8. Heroic techniques to save a limbHeroic techniques to save a limb
ďŹ If vascular repair satisfactory on
arteriogram, but distal extremity
borderline viability because of
â vascular spasm,
â extreme destruction of collateral vessels
in soft tissues or
â prolonged ischaemia.
1. Sympathetic blocks or
sympathectomy of the involved limb.
9. 2. Proximal arterial infusion with
Heparin â Tolazoline â Saline
Solution (1000 U heparin + 500mg
tolazoline in 1000ml saline) @ 30ml/
hr.
3. Venous infusion with
L.M.W.Dextran @ 500ml/ 12hrs.
11. Tumor and limb salvageTumor and limb salvage
ďŹAdvances in imaging, chemotherapy,
radiotherapy & surgical technique
ďŹTreatment of choice in most bone
and soft tissue sarcomas
â Preoperative radiation â soft tissue
sarcomas
â Neoadjuvant chemotherapy â bone
sarcomas
12. Rarely L. S. not possible e.g.Rarely L. S. not possible e.g.
ďŹNeurovascular structures
involvement,
ďŹDisplaced pathological fracture,
ďŹComplications sec to poorly
performed biopsy.
13. Limb salvage / AmputationLimb salvage / Amputation
ďŹExpectations & desires of the
individual and his family.
ďŹSimon â 4 Issues
â Survival (Mortality)
â Morbidity â short & long term
â Function â compared to prosthesis
â Psychosocial consequences
14. LiteratureLiterature
ďŹSeveral studies of comparison of
â Multimodal treatment (Sx + CT)
â Amputation
â Disarticulation
ďŹOsteosarcoma
â Long term survival 20% to 70%
â Local recurrence distal femur lesions 5 â
10% equivalent to transfemoral
amputations.
â Very low in hip disarticulation.
15. ďŹSurvival - No study has proved any
superiority of any surgical technique
comparing
â Limb salvage
â Transfemoral amputation or
â Hip disarticulation
ďŹProvided wide surgical margins
obtained.
16. AmputationAmputation
ďŹTechnically demanding for
malignancy
â Non standard flaps
â Bone graft augmentation â better fxnal
limb
ďŹComplications
â Infection, wound dehiscence
â Chronic painful limb, phantom limb
â Appositional bone growth â revision.
17. Limb salvageLimb salvage
ďŹGreater perioperative and long term
morbidity.
â More extensive surgical procedure.
â Greater risk of infection & wound
dehiscence,
â Flap necrosis
â Blood loss
â DVT
18. ďŹLong term complications
â Periprosthetic fractures
â Prosthetic loosening or dislocation
â Non-union of graft-host junction
â Allograft #
â LLD & late infection
ďŹMultiple future operations.
ďŹ1/3rd
of long term survivors â
amputations.
19. Functional outcome:Functional outcome:
ďŹ Location of tumor most important issue.
ďŹ Resection of upper extremity lesion with limb
salvage even sacrificing 1 or 2 major nerves â
better fxn â than amputation & prosthetic use.
ďŹ Resection of proximal femoral or pelvic lesion
with local recurrence â better fxn â than
disarticulation or hemipelvectomy.
ďŹ Ankle & foot â amputation + prosthetic fitting
better in large sarcomas.
ďŹ Sarcomas around knee - individualized.
20. Osteosarcoma around kneeOsteosarcoma around knee
ďŹ Usually three surgical procedures
1. Wide resection with prosthetic knee
replacement,
2. Wide resection with allograft
arthrodesis &
3. Trans femoral amputation.
ďŹ Less commonly,
â Osteoarticular allograft reconstruction
â Rotationplasty
21. ďŹCompared to transfemoral amputees,
pts. having resection & prosthetic
knee replacement
â demonstrated higher self selected
walking velocities and
â a more efficient gait with regards to O2
consumption.
Otis,lane & kroll
22. Long term functions for tumorsLong term functions for tumors
about kneeabout knee
ďŹ Amputation-
â difficulty walking on steps, rough, slippery
surfaces but
â were active and
â least worried about damaging the effected
limb.
ďŹ Arthrodesis-
â performed most demanding physical work &
recreational activities
â Difficulty in sitting esp. back seat.
Harris et al.
23. ďŹArthroplasty-
â generally led more sedentary life & were
protective of their limb
â Little difficulty in ADL
â Least self concerned about their limb.
ďŹA successful arthrodesis is more
durable in long term than a mobile
joint reconstruction.
25. Leg length discrepancyLeg length discrepancy
ďŹFuture LLD
â Expandable prosthesis
â Limb lengthening procedures
ďŹComplication may out weigh benefits
esp. in children <10 yrs.
â Temporary osteoarticular allograft â to
spare the adjacent physis.
â Disarticulation and rotationplasty.
32. Wide marginsWide margins
ďŹPlane of dissection is
in normal tissue
ďŹNo specific distance
defined.
ďŹCuff of normal tissue
ďŹGoal of most
procedures for high
grade malignancies.
33. Radical marginsRadical margins
ďŹAll compartments that
contain the tumor
removed en bloc
â Soft tissue sarcomas â
⢠removing entire
compartment (or multiple
compartments) of involved
muscles
â Bone tumors-
⢠removing entire bone and
the compartments of any
involved ms. *
34. Oncological standpoint of view:Oncological standpoint of view:
ďŹ8 different surgical procedures
â Resection - with 4 types of margins
â Amputations - with 4 types of margins
ďŹAmputations being usually
â wide or radical (high A K amputations)
â or may be marginal (Hemipelvectomy).
35. RESECTION & RECONSTRUCTIONRESECTION & RECONSTRUCTION
ďŹCurrent treatment for most
musculoskeletal malignancies.
ďŹAggressive benign neoplasms.
ďŹGoal of resection:
â Wide margin if possible and if not
â Marginal margin + C.T. / R.T.
⢠e.g: radiation for soft tissue sarcomas.
â Marginal margin - most benign lesions.
36. ReconstructionReconstruction
ďŹ Allograft arthrodesis still a role in
some circumstances.
ďŹ 3 options available for preserving a
mobile joint:
1. Osteoarticular allograft reconstruction
2. Endoprosthetic reconstruction
3. Allograft prosthesis composite
ďŹ Sometimes rotationplasty.
37. ComplicationsComplications
ďŹOncological procedures have higher
complications due to
â Extensive nature of operations
â Extensive tissue loss
â Side effects of radiation and
chemotherapy
â Generally young pts. with high activity.
ďŹWound necrosis and infection same.
38. Osteoarticular allograftsOsteoarticular allografts
ďŹ Adv:
â Ability to replace ligaments, tendons &
intraarticular structures.
â As a temporary measure to preserve adjacent
physis till skeletal maturity e.g. Prox tibia
ďŹ Disadv:
â nonunion at graft host jxn.
â fatigue #, articular collapse, dislocation,
degenerative jt. dis. & failure of ligament &
tendon attachments.
39. Allograft prosthesis compositesAllograft prosthesis composites
ďŹ Long term soln. for some pts.
ďŹ Adv:
â Avoid deg. jt disorders and articular collapse
â Preserving ability to directly attach soft tissue
structures.
ďŹ Disadv:
â fatigue #, infection and non union at graft host
jxn.
40. Endoprosthetic ReconstructionEndoprosthetic Reconstruction
ďŹ Long term fxn for some pts.
ďŹ Adv:
â Predictable immediate stability
â Quicker rehab with immediate FWB
â Increased durability â better implants.
â Incremental limb lengthening
ďŹ Disadv:
â Long term compl. if pt. is cured of disease.
â polyetheylene wear â inserts replaced.
â Fatigue # common at yoke of a rotating hinge â
replaceable.
â Fatigue # at base of stem â difficult to remove.
41. Segmental bone and joint prosthesisSegmental bone and joint prosthesis
ďŹ Usually secured through composite
fixation
ďŹ Intramedullary stem - fixed with cement â
immediate stability quicker rehab.
ďŹ Shoulder region of prosthesis â porous
coating â
â promoting late extramedullary cortical
bridging
â also protecting cement- bone interface &
â additional structural support.
ďŹ Bonegrafting at shoulder region to
promote extracortical bridging.
43. Upper Extremity:Upper Extremity:
ďŹ Even the best artificial limbs fail to provide
comparable fxn, unlike lower ext.
ďŹ Even with sacrifice of 3 major nerves, limb
salvage is better functional than artificial.
â Prox. humeral resectionâ Axillary N. sacrificed.
â Humeral shaft- Radial N.
ďŹ If median & ulnar Ns sacrificed â L.S. is
better if functioning ms. are available for
transfers.
44. Resection of shoulder girdleResection of shoulder girdle
ďŹScapular tumors-
â extend to glenohumeral jt.
â Extra-articular resection of humeral
head en bloc with scapula
ďŹProximal humeral tumors-
â Extend into the joint through biceps
tendon
â Extra-articular partial scapulectomy
45. Classification: 6 types.Classification: 6 types.
ďŹ TYPE I â Intra-articular prox. humeral
resection.
ďŹ TYPE II â Partial scapular resection.
ďŹ Type III â Intra-articular total
scapulectomy.
ďŹ TYPE IV â Extra-articular total
scapulectomy and humeral head
resection (Classical Tickhoff Linberg)
Malawer et al.
46. ďŹTYPE V âExtra-articular humeral
head resection.
ďŹTYPE VI - Extra-articular humeral
and total scapular resection.
ďŹSubtypes:
â A - Abductor mech. intact.
â B - Partial or complete resection.
47.
48. Tikhoff- Linberg procedure:Tikhoff- Linberg procedure:
ďŹTotal scapulectomy
ďŹPartial/complete excision of clavicle
ďŹExcision of prox. humerus.
ďŹUse:
â Malignant tumors about shoulder joint.
â Usually sacrificing Axillary N. and
sometimes Radial N.
49. Resection of clavicle:Resection of clavicle:
ďŹSubcutaneous â early detection.
ďŹEither end resection.
ďŹEntire bone excision.
ďŹLittle loss of function.
ďŹeg. solitary myelomas, ABC, non
specific granulomatous lesions.
50. Subtotal resection of scapulaSubtotal resection of scapula
ďŹTumors of scapular body wihout
joint involvement is rare.
ďŹE.g. Extraabdominal desmoids, GCT,
Low grade Chondrosarcoma â Partial
scapulectomy
ďŹSubscapularis m. good margin
prevents chest wall invasion.
51. Partial resection of scapulaPartial resection of scapula
ďŹParts of scapula to entire bone.
ďŹE.g. Benign tumors, TB, chronic
ostemyelitis.
ďŹBody alone resected â shoulder is
fairly stable and functional provided
ms. are attached in fxnal positions.
52. Resection of proximal humerus:Resection of proximal humerus:
ďŹBiopsy - Anterior third of deltoid- no
contamination of delto-pectoral
interval.
ďŹUsed in:
â Sarcomas- Resection of prox. humerus
with contiguous soft tissues-
satisfactory margins
â Aggressive benign neoplasms and
metastatic carcinomas of prox.
humerus.
53. Reconstructive alternatives:Reconstructive alternatives:
1. Flial shoulder
2. Passive Spacer â Allograft or
autograft, fibular or prosthetic
implants ( better cosmesis / fxn).
3. Arthroplasty (implant or allograft).
4. Arthrodesis e.g. Enneking method
55. Resection of distal humerusResection of distal humerus
ďŹ Lesions in elbow requiring limb salvage
are rare.
ďŹ Occasional malignant/ aggressive benign
lesions like Chondroblastoma or GCT.
ďŹ Reconstruction options-
â Flial elbow
â Osteaoarticular allograft
â Implant arthroplasty
â Arthrodesis
56. Resection of proximal radius / ulnaResection of proximal radius / ulna
ďŹConsiderable portion can be
resected without reconstruction in
radius.
57. Resection of distal radius:Resection of distal radius:
ďŹE.g. GCT
ďŹReconstruction by:
â Arthroplasty,
â Arthrodesis using allograft or auto graft.
ďŹProximal fibular auto graft
reconstruction arthroplasty
â Maintain motion but light activities.
ďŹArthrodesis
â Sacrifice motion but more stable.
58. Resection of distal ulnaResection of distal ulna
ďŹNo reconstruction needed.
ďŹPeriosteum is excised with the
tumor.