limb salvage of lower extremity

RECONSTRUCTIVE SURGERIES OF RECONSTRUCTIVE SURGERIES OF TUMORS AROUND HIP AND KNEE JOINT TUMORS AROUND HIP AND KNEE JOINT (LIMB SALVAGE SURGERIES)(LIMB SALVAGE SURGERIES)

Dr. Sushil Paudel

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

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

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}

Preoperative evaluation Preoperative 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

Biopsy

Principles of biopsy Principles 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.

Osteosarcoma

Plain X-ray Affected bone and joint

Chest X-ray

Skeletal survey

MRI: Investigation of choiceSoft tissue extent

Skip lesion

Vascularity of tumor

Neurovascular involvement

Radiological investigations

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..)

MRI DSA

Staging of tumor Staging of tumor Enneking system : Benign tumor : Latent

Active Aggressive

Malignant tumor

Stage Grade Site Metastasis

IA G1 T1 M0IB G1 T2 M0IIA G2 T1 M0IIB G2 T2 M0III G1-2 T2 M1

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.

Psychosocial and Psychosocial and functional evaluationfunctional evaluation Musculoskeletal tumor society functional

score.• Pain, function, acceptance,gait.

Short form 36.Toronto extremity salvage score.

Role of chemotherapy and Role of chemotherapy and radiotherapy radiotherapy

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

Regimen of chemotherapy of osteosarcoma: Regimen of chemotherapy of osteosarcoma: AIIMS Protocol AIIMS 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

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

Surgical margin

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

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

Salvaged limbSalvaged limb

Acceptable degree of function

Cosmetic appearance

Minimal amount of pain

Durable enough to withstand the

demands of normal daily activities

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 epiphysisPulmonary metastasis is not a contraindication

of surgery Contraindications of limb salvage are the indications for amputation

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

Principles & TechniquesPrinciples & Techniques

Resection of tumor – Principles of surgical oncology

Skeletal reconstruction – Principles of orthopaedic surgery

Soft tissue & muscle transfer – Principles of plastic surgery

Resection of tumor : Intra articular Extra articular

Margin 5-7 cm *Adherent neurovascular bundles - amputation Surgical margin - near neurovascular bundle

(* OCNA JAN 91)

KNEE

Methods of ReconstructionMethods of Reconstruction

Arthrodesis Mobile joint reconstruction Osteoarticular allograft Endoprosthetic replacement Allograft Endoprosthetic composite Rotationplasty Autoclaved tumor bone

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

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

ARTHRODESIS OF HIP

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

Postoperative Postoperative

TURN O PLASTY

TURN O PLASTY

RECONSTRUCTION USING BONE GRAFT

Non-articular (Intercalary)

Articular reconstruction

Autograft

Allograft

Non-articular(Autogenous) graftAdvantage : 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)

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

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

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.) :

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

Osteoarticular graft (distal femur)

Large graftRigid 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

Reconstructions using autoclaved Reconstructions using autoclaved bone graftbone graft

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

Proximal femoral endoprosthesis

Oldest, widely used method

Treatment of choiceTreatment of choice of patient with limited life expectancy

Type of endoprosthesisBipolar THR:

Short stem Long stem

Proximal femoral endoprosthesisAdvantage

No prolong protected weight bearing Good ambulatory gait No risk of transmission of disease / infection

Disadvantage Mechanical failure Loosening Stress fracture

Proximal femoral endoprosthesis14-18 mm diameter : Age, Size of patient and

Diameter of femur Length 135-200mmAnterior bow

Modular prosthesis : Extramedullary porous in growth material on the segment proximal to stem.

Trial in reduction

Postoperative Hip spica Instability during surgery : Abduction brace : 2-3 months

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

Segmental custom made total knee replacement

Indications Primary malignant tumor Metastatic tumor Stage three begin tumor

MODULAR CUSTOM MADE KNEE JOINT

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

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

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

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

Alloprosthesis Endoprosthesis fixed to a allograft rigidly fixed with host

boneHIP: 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

Younger patients Younger patients

Rotation plasty : Act like a below knee amputation

Expandable prosthesis

Arthrodesis of hip

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

ROTATIONPLASTY

AII

BI

BII

BIII

AI

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

Expandable prosthesis :

Hollow titanium tube assembled over a threaded shaft and fitted with a adjustable ring.

Lengthening : -1 to 2 cm at a time

Soft tissue reconstruction HIP-CapsuleAbductor

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

Extensor mechanism KNEE JOINTPatellar 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°

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

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

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