limb salvage

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  • LIMB SALVAGE SURGERY

  • Limb SalvageTRAUMATUMOR

  • Limb salvage and traumaStarts at E.R. when a mangled extremity arrives series of decisionsIf life in danger, should the mangled limb be amputatedIf stable, should an attempt be made to salvage the mangled limbIf salvage, what is the sequence of repairsIf salvage fails, when should amputation be performed.

  • Most difficult decisionWhether to attempt salvage or not5 Scoring systems published

    Author / YearNameCriteriaGregory et al.1985Mangled Extremity Syndrome Index9Seiler et al.1986- 4Howe et al.1987Predictive Salvage Index PSI4Johansen et al.1990Mangled Extremity Severity Score (MESS)- Prospective4Russell et al.1991Limb Salvage Index (LSI)7

  • Mangled Extremity Severity Score

  • Two major criteriaImmediate amputation Vs attempted salvage, if either present- amputation better choice.Loss of arterial inflow >6 hrs., esp. in presence of a crush injury which disrupts collateral vessels.Disruption of posterior tibial nerve.

  • Relative indications of amputation in Gustilo III-C tibial #sLange & Hansen et al.Serious associated polytrauma.Severe ipsilateral foot trauma.Anticipated protracted course for soft tissue coverage and tibial reconstruction.If 2 of these present immediate amputation is recommended.

  • Heroic techniques to save a limbIf vascular repair satisfactory on arteriogram, but distal extremity borderline viability because of vascular spasm,extreme destruction of collateral vessels in soft tissues or prolonged ischaemia.Sympathetic blocks or sympathectomy of the involved limb.

  • Proximal arterial infusion with Heparin Tolazoline Saline Solution (1000 U heparin + 500mg tolazoline in 1000ml saline) @ 30ml/ hr.Venous infusion with L.M.W.Dextran @ 500ml/ 12hrs.

  • TUMOR AND LIMB SALVAGE

  • Tumor and limb salvageAdvances in imaging, chemotherapy, radiotherapy & surgical techniqueTreatment of choice in most bone and soft tissue sarcomasPreoperative radiation soft tissue sarcomasNeoadjuvant chemotherapy bone sarcomas

  • Rarely L. S. not possible e.g.Neurovascular structures involvement,Displaced pathological fracture,Complications sec to poorly performed biopsy.

  • Limb salvage / AmputationExpectations & desires of the individual and his family.Simon 4 Issues Survival (Mortality)Morbidity short & long termFunction compared to prosthesisPsychosocial consequences

  • LiteratureSeveral studies of comparison of Multimodal treatment (Sx + CT)AmputationDisarticulationOsteosarcomaLong term survival 20% to 70%Local recurrence distal femur lesions 5 10% equivalent to transfemoral amputations.Very low in hip disarticulation.

  • Survival - No study has proved any superiority of any surgical technique comparingLimb salvageTransfemoral amputation orHip disarticulationProvided wide surgical margins obtained.

  • AmputationTechnically demanding for malignancyNon standard flapsBone graft augmentation better fxnal limbComplicationsInfection, wound dehiscenceChronic painful limb, phantom limbAppositional bone growth revision.

  • Limb salvageGreater perioperative and long term morbidity.More extensive surgical procedure.Greater risk of infection & wound dehiscence,Flap necrosisBlood lossDVT

  • Long term complicationsPeriprosthetic fracturesProsthetic loosening or dislocationNon-union of graft-host junctionAllograft #LLD & late infectionMultiple future operations.1/3rd of long term survivors amputations.

  • Functional outcome:Location of tumor most important issue.Resection of upper extremity lesion with limb salvage even sacrificing 1 or 2 major nerves better fxn than amputation & prosthetic use.Resection of proximal femoral or pelvic lesion with local recurrence better fxn than disarticulation or hemipelvectomy.Ankle & foot amputation + prosthetic fitting better in large sarcomas.Sarcomas around knee - individualized.

  • Osteosarcoma around kneeUsually three surgical proceduresWide resection with prosthetic knee replacement,Wide resection with allograft arthrodesis &Trans femoral amputation.Less commonly,Osteoarticular allograft reconstructionRotationplasty

  • Compared to transfemoral amputees, pts. having resection & prosthetic knee replacement demonstrated higher self selected walking velocities and a more efficient gait with regards to O2 consumption.Otis,lane & kroll

  • Long term functions for tumors about kneeAmputation-difficulty walking on steps, rough, slippery surfaces but were active andleast worried about damaging the effected limb.Arthrodesis- performed most demanding physical work & recreational activitiesDifficulty in sitting esp. back seat. Harris et al.

  • Arthroplasty-generally led more sedentary life & were protective of their limbLittle difficulty in ADLLeast self concerned about their limb. A successful arthrodesis is more durable in long term than a mobile joint reconstruction.

  • Allograft-prosthetic composite reconstructionLocation is important.Proximal reconstruction generally outlast more distal ones ( Inverse of prognosis).Prox. femoral > distal femoral > prox tibial.

  • Leg length discrepancyFuture LLDExpandable prosthesisLimb lengthening proceduresComplication may out weigh benefits esp. in children
  • Psychological outcomeNo evidence of any significant diff.Pt must make the final decisionShort & long term goalsLifestyle modifications.

  • Margins of tumorOncological surgical procedures,margins should be definedAmputation / Resection.

  • Orthopedic oncologyFour termsIntralesionalMarginalWideRadical

  • Intralesional marginsPlane of dissection is within the tumor,Gross residual tumorSymptomatic benign lesionsDebulkingPalliative procedure in metastatic disease.

  • Marginal marginClosest plane of dissection passes through the pseudocapsule.Most benign lesionsSome low grade malignanciesSelective high grade malignancies + preop. radiotherapy and neoadjuvant chemotherapy

  • Pseudocapsule contains microscopic foci of disease / satellite lesions.Local recurrance if not responding to C.T. / R.T.

  • Wide marginsPlane of dissection is in normal tissueNo specific distance defined.Cuff of normal tissueGoal of most procedures for high grade malignancies.

  • Radical marginsAll compartments that contain the tumor removed en bloc Soft tissue sarcomas removing entire compartment (or multiple compartments) of involved musclesBone tumors-removing entire bone and the compartments of any involved ms. *

  • Oncological standpoint of view:8 different surgical proceduresResection - with 4 types of marginsAmputations - with 4 types of marginsAmputations being usually wide or radical (high A K amputations) or may be marginal (Hemipelvectomy).

  • RESECTION & RECONSTRUCTIONCurrent treatment for most musculoskeletal malignancies.Aggressive benign neoplasms.Goal of resection:Wide margin if possible and if notMarginal margin + C.T. / R.T.e.g: radiation for soft tissue sarcomas.Marginal margin - most benign lesions.

  • ReconstructionAllograft arthrodesis still a role in some circumstances.3 options available for preserving a mobile joint:Osteoarticular allograft reconstructionEndoprosthetic reconstructionAllograft prosthesis compositeSometimes rotationplasty.

  • ComplicationsOncological procedures have higher complications due toExtensive nature of operationsExtensive tissue lossSide effects of radiation and chemotherapyGenerally young pts. with high activity.Wound necrosis and infection same.

  • Osteoarticular allograftsAdv:Ability to replace ligaments, tendons & intraarticular structures.As a temporary measure to preserve adjacent physis till skeletal maturity e.g. Prox tibiaDisadv:nonunion at graft host jxn.fatigue #, articular collapse, dislocation, degenerative jt. dis. & failure of ligament & tendon attachments.

  • Allograft prosthesis compositesLong term soln. for some pts.Adv:Avoid deg. jt disorders and articular collapsePreserving ability to directly attach soft tissue structures.Disadv:fatigue #, infection and non union at graft host jxn.

  • Endoprosthetic ReconstructionLong term fxn for some pts.Adv: Predictable immediate stabilityQuicker rehab with immediate FWBIncreased durability better implants.Incremental limb lengtheningDisadv:Long term compl. if pt. is cured of disease.polyetheylene wear inserts replaced.Fatigue # common at yoke of a rotating hinge replaceable.Fatigue # at base of stem difficult to remove.

  • Segmental bone and joint prosthesisUsually secured through composite fixationIntramedullary stem - fixed with cement immediate stability quicker rehab.Shoulder region of prosthesis porous coating promoting late extramedullary cortical bridging also protecting cement- bone interface & additional structural support.Bonegrafting at shoulder region to promote extracortical bridging.

  • SURGICAL TECHNIQUEUpper ExtremityLower Extremity &Pelvis

  • Upper Extremity:Even the best artificial limbs fail to provide comparable fxn, unlike lower ext.Even with sacrifice of 3 major nerves, limb salvage is better functional than artificial.Prox. humeral resection Axillary N. sacrificed.Humeral shaft- Radial N.If median & ulnar Ns sacrificed L.S. is better if functioning ms. are available for transfers.

  • Resection of shoulder girdleScapular tumors-extend to glenohumeral jt.Extra-articular resection of humeral head en bloc with scapulaProximal humeral tumors-Extend into the joint through biceps tendonExtra-articular parti

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