This document discusses principles of limb salvage surgery for bone and soft tissue tumors. Key points include defining limb salvage as resection of tumor with acceptable oncological, functional and cosmetic results while preserving the limb. Patient selection, historical background, surgical principles for different tumor stages and sites are covered. Reconstruction options including allografts, prostheses and arthrodesis are summarized for different skeletal defects involving joints, the diaphysis and epiphysis.

1. LIMB SALVAGE SURGERY
Dr Dharma Ram Poonia
RGCI & RC
08.06.2016
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2. • DEFINITION AND INTRODUCTION
• PATIENT SELECTION
• HISTORICAL BACKGROUND
• SURGICAL PRINCIPLES stage 1 to 3
• INDIVIDUAL SITES
• COMPLICATION AND SURVIVAL
• FUTURE
• SUMMARY
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3. DEFINITION
Surgical resection of tumor of limb with acceptable oncological,
functional and cosmetic results.
GOAL
• Functional and painless limb
• Oncological acceptable
• Durable enough to withhold demand of normal activities
SCOPE
• Trauma
• Vascular insufficiency
• Bone tumor
• Soft tissue tumor 2

4. PATIENT SELECTION
3

5. HISTORICAL BACKGROUND
• Classically amputation was standard of care for most bone tumor, but OS
was 10-15% in 1960-70.
• With advent of improved CT  prognosis improved significantly
• Post Rosenberg’s landmark trial ,1980-90 was era when LSS gained
popularity.
• Skeletal Reconstruction was main obstacle in rapid growth
• Initially only custom made prosthesis available, hence concept of induction
chemo by Rosen and Marcove , till prosthesis can me manufactured. 1980-
90
• Lexer – 1st successful series of 6 pts using allografts. 1907
• 1940  austin moore and Bohlman : Custom made Prosthesis for GCT
• 1970  Francis and Marcove : current age prosthesis for Osteosacoma
4

6. • Rosenberg et al Ann Surg 1982. (NCI)
• PRCT, 43 patients
• LSS + RT Vs Amputation with Chemotherapy.
• Local Recurrence  15% vs 0, (NS)
• No Difference in 5 year OS and DFS.
They conclude increased LR, is not affecting Survival
and perhaps these patients are more likely to develop
DM (their disease biology ) even if Local control with
Amputation
Limb-Sparing Treatment of Adult Soft-Tissue Sarcomas and
Osteosarcomas. NIH Consensus Statement Online 1984;5(6):1–7.
Amputation or LSS
NCI 1982
5

7. Functional outcome & QOL : COMPARABLE
Oncological outcome: superiority
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8. • Now with modern Rx, about 90-95% Patients are candidate
for LSS
• Rate of amputation reduced to 5% from >40 % over last 3
decades.
• MSKCC
• Amputation is must only if .
• Patient preference or
• if oncological sound resection is expected to render the
limb nonfunctional.
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9. AMPUTATION
• Procedure is simple
but
• Non standard flaps
• Complications
• Infection, wound
dehiscence
• Chronic painful limb,
phantom limb
LSS, still favored  Functional outcome, psychological
and cosmetic factors
• Risk of infection & wound
dehiscence,
• Flap necrosis
• Blood loss
• DVT
• Long term complications
• Peri prosthetic fractures
• Prosthetic loosening or dislocation
• Non-union of graft-host junction
• Allograft #
• Multiple future operations
• 1/3rd of long term survivors –
amputations.
LSS
MALAWER 2009
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10. PATIENT SELECTION
• LSS should be considered  if the tumor can
be removed with an adequate margin and the
resulting limb has satisfactory function
• Stage I and Stage IIA  reconstruction is limited to
restoration of skeletal stability.
• stage IIB and III, LSS usually feasible post NACT
• Stage IIB and III —> skeletal and soft-tissue reconstruction
must be performed.
• Final surgical decision should be made following the
completion of neoadjuvant treatment.
MALAWER 2009
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11. PATIENT SELECTION
• Patients with uncontrollable disease
• LSS should be considered if the surgery can be done with
minimum morbidity and rapid return to function, because , it
offers
• immediate stability and rapid mobilization
• avoiding the need for prolonged bracing, crutches, or inpatient
rehabilitation
• improved quality of life
• intact body image
• even if they may not survive long
So, No justification for limiting the limb salvage process based
only on the prognosis
MALAWER 2009
10

12. BARRIERS OF LSS
• Poorly placed biopsy incisions
• Major Vascular involvement
• Encasement of a major motor nerve
• pathological fracture of the involved bone
• Infection
• inadequate motors after resection.
Barriers but not absolute contraindications.
• Pathological fractures, that heals with chemotherapy and the specimen can be removed
with adequate margins.
• Ability to transfer motors, graft nerves and vessels and provide skin cover with
microsurgical methods have allowed successful limb salvage despite many barriers.
Non responding to Chemo is not contraindication
Metastatic disease too is not contraindication
Pan compartmental, fungating growth
Displaced #, not healed after chemo
MALAWER 2009
11

13. Bone
Nerves
Vessels
Soft tissue envelope
If three of these key components are involved, the
limb salvage is probably not worth considering
Three strike rule :
Doctrine now not absolute statement anymore
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14. SURGICAL PRINCIPLES
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15. STAGES OF Limb Salvage Sx
• Tumor resection
• Principle of Surgical oncology
• Stable, painless skeletal reconstruction.
• principle of Orthopedic surgery
• Surrounding and supporting soft tissue is
reconstruction.
• Principle of Plastic surgery 14

16. I. TUMOR RESECTION
• Most critical step
• Optimal resection
• with max preservation of soft tissue
• with adequate Margin
• controversial
• 3 cm for bone, 1-2 cm for soft tissue
• Confirm with FS
• Keep amputation for Oncological sound resection as an option with
consent
• Resultant defect will dictate  subsequent measures.
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17. Skeletal Defects
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18. Joint involving defects : Stage II
1. Resection arthrodesis
2. Osteoarticular allograft recon
3. Mega prosthesis
• Expandable prosthesis
4. Allograft Prosthetic composite (APC)
5. Rotationoplasty
17

19. 1. Resection arthrodesis
• When large defect with no tissue available for reconstruction,
as it was in past in the absence of NACT and micro vascualr
flaps
• Defect covered with vascularized/non vascularized , fibula/Iliac crest, allograft
or autograft.
• Fixation done with plating or nailing
• Stiff limb and non mobile joint, so functionally poor
• Needs prolong immobilization for healing
• Patient can engage in strenuous activities.
Rarely acceptable and rarely offered in
current clinical practice.
Cost effective and useful for flail patients
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20. 2. Osteo Allograft Recon
• Biological tissue, so better incorporation, anticipated.
• Higher acute complication  infection (5-15%), fracture
(15-20%), Non-union (15-20%) and osteoarthritis
• Late complications such as instability and allograft fracture.
• Overall complication rates can exceed 50%, even when
performed at a major center
• Concern of potential for the transmission of
bacterial or viral disease.
So in current clinical practice these are
not used except for intercalary defects.
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21. 3. Mega prosthesis
• Large metallic joint, designed to replace excised joint and
adjacent bone.
• Currently 2nd generation prosthesis in use, made of stronger metals
and superalloys like titanium and Chrome-cobalt
• Available for
• Proximal, distal and total humerus,
• Distal, proximal and total femur,
• Proximal tibia prosthesis available.
• Earlier customized
• Modular system available.
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22. PROSTHESIS EVOLUTION
• Modular Flexibity for surgeon, as any defect can be handled
on table and no need for waiting.
• First generation : Howmedica Modular replacement System (HMRS,
Ireland)
• Cement less fixation with external screwing
• Simple hinge design for Knee
• Higher aseptic stem loosening, screw fracture, polyethylene
failure.
• Currently out of clinical practice
• 2nd Generation : Present day 1990-2000
• Saddle endoprosthesis (Germany)
• Modular segmental Replacement system (MSRS)
• Global Modular replacement system (GMRS)
• Indian made : ReStore system
• Custom made prosthesis still available for difficult case
scenarios and difficult locations
21

23. T
e
c
h
n
.
a
s
p
e
c
t
s
• Cemented Stem fixation – early ambulation and
wt bearing
• Multiple diameter stems - proper largest sized
stem use – minimal risk of fracture.
• Circumferential porous coating – permit ingrowth
of bone graft and makes pseudo capsule and
isolate prosthesis for periprosthetic fluid.
• Rotating hinge – enable joint movement in the
absence of ligament.
• Metal loops - to permit dependable soft-tissue
reattachment and fibrous ingrowth into the
prosthesis.
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24. Expandable Prosthesis
• Child r not small adult
• Special prosthesis  periodically
lengthening
• Worm gear mech  Screwing allow
increase telescoping cylinder length.
• Screwing methods : manual with small
incision under anesthesia each time
• Recently highly sophisticated remotely
screwing prosthesis developed using
Electro Magnetic field.
• Cost is main concern
• Repeated intervention is another
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25. Endoprosthetic Reconstruction
Advantage
• Predictable
immediate stability
• Quicker rehab with
immediate
mobilization
• Increased
durability – better
implants.
• Incremental limb
lengthening
Disadvantage
• Polyethylene wear
– inserts replaced.
• Fatigue # at hinge
• Fatigue # at base
of stem – difficult
to remove.
• Aseptic loosening
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26. 4. APC
• Thought to be
• benefits of a biologic reconstruction along with the
immediate stability achieved by a cemented
endoprosthesis.
• But complication of pure biological recon persisted.
• Better suited for a patient undergoing revision of a failed
allograft
Limited use in current clinical practice
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27. 5. Rotationoplasty
• Salzer 1974
• Ankle joint used to substitute
resected Knee after 180 degree
rotation.
• After resection  Fuse distal
segment (tibia) with proximal
femur, so Ankle joint come at
level of Knee.
• Ankle joint now reach at level of
opposite knee and act as Knee.
• Special external prosthesis
applied over there.
AGARWAL 2012
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28. • Advantage
• cheaper and less complex Surgery.
• sole being the normal weight bearing area, there is no
phantom pain.
• Less pain and more able to participate in heavy work as
compared to megaprosthesis. so in summary —>
• Functional results are comparable with Endoprosthetic recon
• but limb disfigurement a/w psychological barrier to
acceptance.
AGARWAL 2012
27

29. Intercalary defects : Stage II
About It is now possible to save the joint even if only 1.5-
2cms of condyle thickness remain.
• Options are
• Allograft or autograft
• Tumor bearing bone re implantation
• Prosthesis
28

30. 29

31. Allografts and Auto grafts
• Results of these options : high complication but better than
joint involving defects.
• Despite the large cancellous bony contact surface, lack of rigid
fixation at the epiphyseal end delayed the average time to
union to 18 months compared to 13 months at metaphyseal
end
• Vascularized fibula  good option
• Better union rate (90% vs. 70%)
• Non vascularized Fibula, (union rate 89% Krieg et al)
• For larger defects Allo- auto combinations can be used.
• The allograft provides the initial strength and the vascularised
autograft provides speed of union 30

32. ReImplantation of Tumor bone
• Autoclaving, pasteurization, freezing with liquid nitrogen, or
extracorporeal radiation to kill the tumor cells  low cost
option.
• Though dead like allograft, perfect match of defect
• Non union with ECRT  7% (43% with allograft)
• Bone union time 6-7 months
• Similar fracture rates
• These are reasonable options
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33. Prosthesis
• Endoprosthetic reconstruction of a diaphyseal defect
• avoids the donor site morbidity of autograft and
• the fracture and non-union risk of allograft especially for patients
on chemotherapy.
• It also shortens surgical time significantly as compared to a VF.
• Clinical results have been at least as good as allografts.
• Customised HA coated implants have been used for
epiphyseo- diaphyseal defects.
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34. Hemicortical defects : Stage II
• Its used for partial circumferential excision of benign or low
grade tumors like a parosteal osteosarcoma
• Recon with shaped autograft or allograft by Fibula or iliac
crest.
33

35. a. Pelvic Resection stage 2
• Type 1 and 3  Often No recon needed
• Type 2 resection 
• Saddle prosthesis
• Composite allografts
• Partial pelvic prosthesis(Stryker) :
• high acetabular resection
• Resection arthrodesis/ Psedoprosthesis
34

36. Stage 3 principles
• Joint capsule augmentation : by Psoas, extensor rotators and Dacron
tapes
• Abductor mechanism
• To to minimize trendelneberg lurch and strengthening of
abductor power
• Hip abductors as trochanteric claw or with Dacron tap  fix to
prosthesis
• 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
• Stability  balancing the muscle tension between the medial
iliopsoas and the lateral hip abductors. 35

37. b. Proximal & Total Femur
36

38. c. Distal femur
• MC site of tumor
• options
• Prosthetic knee
replacement
• Allograft
arthrodesis &
• Trans femoral
amputation.
• Less commonly
• Osteoarticular
allograft
reconstruction
• Rotationplasty
• Patellar resurfacing
is not found to
improve function
• Extensor mech
not needed 37

39. d. Proximal tibia 1. proximal tibia  skin necrosis prone
2.
38

40. e. Pectoral resection
• Flail shoulder
• Passive Spacer – Allograft
or autograft, fibular or
prosthetic implants ( better
cosmesis / fxn).
• Arthroplasty (implant or
allograft).
• Arthrodesis
Allograft arthrodesis
39

41. • If large high grade tumor of humerus/ scapula
extra articular resection with rotator cuff 
• Pain less static limb is goal  functional use of the elbow,
forearm, wrist, and hand.
• static suspension with Heavy suture, Dacron tapes, Gore tex
graft
• Dynamic suspension by local muscle transfers
that stabilize the shoulder and facilitate internal
rotation (i.e. transfer of the pectoralis major), so
useful if substantial muscles preserved.
• 40

42. • If low grade tumor or palliative resection 
preserve much of muscles  better functional
outcome.
• Wherever the deltoid and axillary nerve can be
preserved, a reverse shoulder implant can be
used.
• Scapular endoprosthesis after a scapulectomy
may provide better function than simple
humeral suspension of the latissimus dorsi,
trapezius, deltoid and rhomboids can be
preserved with better abduction and flexion
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43. f. Distal Humerus/ Elbow
• Rare.
• Occasional malignant/ aggressive benign lesions like
Chondroblastoma or GCT.
• Reconstruction options-
• Flail elbow
• Osteaoarticular allograft
• Arthrodesis
• Implant arthroplasty : Biceps insertion is key for function
• Considerable portion of proximal radius can be resected
without reconstruction.
• Distal Radius resection need some form of recon while distal
ulna resection don’t need recon
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44. LSS for Children
• Children over 10 to 12 years of age
• Treated similarly to adults, using smaller versions of the modular
prostheses.
• For children younger than 5 years,
• primary amputation remains the preferred solution.
• So from 5 to 12 years is challenging area
• Expandable prosthesis
• Distraction orthogenesis
• Rotationoplasty
43

45. Skin closure
• for larger tumor often extra skin available owing to pressure of
growing tumor, extra skin along incision area should be
resected to avoid margin necrosis due to regional
devascularization (large flaps).
• sometimes if skin is lesser —> SSG
• Limb elevation in post op period to reduce swelling.
• Large bore suction drains always placed
• if hematoma or wound breakdown —> immediate re
exploration to avoid infection of endoprosthesis.
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46. COMPLICATIONS
• Most early complication of wound infection, edema, flap
necrosis are related to their poor immunity and clotting
derangement (Post Chemo)
• Prosthetic fracture,
• disassociation of modular components,
• fatigue failure, and
• polyethylene wear
• Improved implant designs, metallurgy, and manufacturing
techniques has reduced the incidence of these problems
significantly.
• A recent series of 200 MRS,  no stem fractures, body
fractures, or taper disassociations past more than 18 year FU
• Polyethylene bushing failure occurs in fewer than 5% of
patients with the hinge mechanism.
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47. 116 LSS by Nov 2012
Patients of osteosarcoma 51
Reported results of OS only
OS3  66%
EFS3  61.8%
Best functional score with
proximal
& distal femur, least with Knee
arthrodesis
46

48. ENDO PROSTHESIS SURVIVAL
• “removal of the prosthesis for any reason”
• MC early cause  Infection 7%, reduced dramatically
• overall survival of 88% at 5 years and 85% at 10 years
• Infected patients having an 83% risk of implant failure.
• Functional results vary by implant location.
• Outcomes following reconstruction of the distal femur reported best
 as good to excellent in 85% of patients.
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49. FUTURE ..
• Premixed antibiotic cement, Available but not in routine
practice
• Improved method of tendon attachment to prosthesis
• Next generation expandable prosthesis (Rephysis) under
development (custom made)
• New fixation method; Hydroxyapatite stem
• Compress system of Prosthesis fixation
• Artificially engineered living bone might replace endo
prosthesis 48

50. In Brief
• Limb salvage has become accepted standard care of the
patients with malignant bone tumors
• Achieving a surgical margin that will ensure a low rate of
local recurrence is paramount
• A variety of techniques are available with appropriate
surgical method should be chosen for optimal function
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51. Thank you.
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