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LIMB SALVAGE SURGERY LIMB SALVAGE SURGERY

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LIMB SALVAGE SURGERYLIMB SALVAGE SURGERY

Limb SalvageLimb Salvage

TRAUMA TUMOR

Limb salvage and traumaLimb salvage and trauma Starts at E.R. when a mangled

extremity arrives – 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.

Most difficult decisionMost difficult decision Whether to attempt salvage or not 5 Scoring systems published

Author / Year Name CriteriaGregory et al.1985 Mangled Extremity

Syndrome Index9

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

Mangled Extremity Severity ScoreMangled Extremity Severity Score

Two major criteriaTwo major criteria

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.

Relative indications of amputation in Relative 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.

If 2 of these present immediate amputation is recommended.

Heroic techniques to save a limbHeroic techniques to save a limb

If 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.

1. Sympathetic blocks or sympathectomy of the involved limb.

2. Proximal arterial infusion with Heparin – Tolazoline – Saline Solution (1000 U heparin + 500mg tolazoline in 1000ml saline) @ 30ml/ hr.

3. Venous infusion with L.M.W.Dextran @ 500ml/ 12hrs.

TUMOR AND LIMB SALVAGETUMOR AND LIMB SALVAGE

Tumor and limb salvageTumor and limb salvage

Advances in imaging, chemotherapy, radiotherapy & surgical technique

Treatment of choice in most bone and soft tissue sarcomas– Preoperative radiation – soft tissue

sarcomas– Neoadjuvant chemotherapy – bone

sarcomas

Rarely L. S. not possible e.g.Rarely L. S. not possible e.g.

Neurovascular structures involvement,

Displaced pathological fracture,Complications sec to poorly

performed biopsy.

Limb salvage / AmputationLimb salvage / Amputation

Expectations & desires of the individual and his family.

Simon – 4 Issues – Survival (Mortality)– Morbidity – short & long term– Function – compared to prosthesis– Psychosocial consequences

LiteratureLiteratureSeveral studies of comparison of

– Multimodal treatment (Sx + CT)– Amputation– Disarticulation

Osteosarcoma– Long 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 comparing– Limb salvage– Transfemoral amputation or– Hip disarticulation

Provided wide surgical margins obtained.

AmputationAmputation

Technically demanding for malignancy– Non standard flaps– Bone graft augmentation – better fxnal

limb

Complications– Infection, wound dehiscence– Chronic painful limb, phantom limb– Appositional bone growth – revision.

Limb salvageLimb salvage

Greater perioperative and long term morbidity.– More extensive surgical procedure.– Greater risk of infection & wound

dehiscence,– Flap necrosis– Blood loss– DVT

Long term complications– Periprosthetic fractures– Prosthetic loosening or dislocation– Non-union of graft-host junction– Allograft #– LLD & late infection

Multiple future operations.1/3rd of long term survivors –

amputations.

Functional outcome: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 kneeOsteosarcoma around knee

Usually three surgical procedures1. Wide resection with prosthetic knee

replacement,

2. Wide resection with allograft arthrodesis &

3. Trans femoral amputation.

Less commonly,– Osteoarticular allograft reconstruction– Rotationplasty

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 Long term functions for tumors about kneeabout knee Amputation-

– difficulty walking on steps, rough, slippery surfaces but

– were active and– least worried about damaging the effected

limb.

Arthrodesis- – performed most demanding physical work &

recreational activities– Difficulty in sitting esp. back seat.

Harris et al.

Arthroplasty-– generally led more sedentary life & were

protective of their limb– Little difficulty in ADL– Least self concerned about their limb.

A successful arthrodesis is more durable in long term than a mobile joint reconstruction.

Allograft-prosthetic composite Allograft-prosthetic composite reconstructionreconstructionLocation is important.Proximal reconstruction generally

outlast more distal ones ( Inverse of prognosis).

Prox. femoral > distal femoral > prox tibial.

Leg length discrepancyLeg length discrepancy

Future LLD– Expandable prosthesis– Limb lengthening procedures

Complication may out weigh benefits

esp. in children <10 yrs.– Temporary osteoarticular allograft – to

spare the adjacent physis.– Disarticulation and rotationplasty.

Psychological outcomePsychological outcome

No evidence of any significant diff.Pt must make the final decision

– Short & long term goals– Lifestyle modifications.

Margins of tumorMargins of tumor

Oncological surgical procedures,

– margins should be defined

– Amputation / Resection.

Orthopedic oncologyOrthopedic oncology

Four terms1.Intralesional

2.Marginal

3.Wide

4.Radical

Intralesional marginsIntralesional margins

Plane of dissection is within the tumor,

Gross residual tumor

Symptomatic benign lesions

Debulking Palliative

procedure in metastatic disease.

Marginal marginMarginal margin

Closest 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 marginsWide margins

Plane of dissection is in normal tissue

No specific distance defined.

Cuff of normal tissueGoal of most

procedures for high grade malignancies.

Radical marginsRadical margins

All compartments that contain the tumor removed en bloc – Soft tissue sarcomas –• removing entire

compartment (or multiple compartments) of involved muscles

– Bone tumors-• removing entire bone and

the compartments of any involved ms. *

Oncological standpoint of view:Oncological standpoint of view:

8 different surgical procedures– Resection - with 4 types of margins– Amputations - with 4 types of margins

Amputations being usually – wide or radical (high A K amputations)– or may be marginal (Hemipelvectomy).

RESECTION & RECONSTRUCTIONRESECTION & RECONSTRUCTION

Current treatment for most musculoskeletal malignancies.

Aggressive benign neoplasms.Goal of resection:–Wide margin if possible and if not–Marginal margin + C.T. / R.T.• e.g: radiation for soft tissue sarcomas.

–Marginal margin - most benign lesions.

ReconstructionReconstruction

Allograft arthrodesis still a role in some circumstances.

3 options available for preserving a mobile joint:

1. Osteoarticular allograft reconstruction

2. Endoprosthetic reconstruction

3. Allograft prosthesis composite

Sometimes rotationplasty.

ComplicationsComplications

Oncological procedures have higher complications due to– Extensive nature of operations– Extensive tissue loss– Side effects of radiation and

chemotherapy– Generally young pts. with high activity.

Wound necrosis and infection same.

Osteoarticular allograftsOsteoarticular allografts

Adv:– Ability to replace ligaments, tendons &

intraarticular structures.– As a temporary measure to preserve adjacent

physis till skeletal maturity e.g. Prox tibia

Disadv:– nonunion at graft host jxn.

– fatigue #, articular collapse, dislocation, degenerative jt. dis. & failure of ligament & tendon attachments.

Allograft prosthesis compositesAllograft prosthesis composites

Long term soln. for some pts. Adv:

– Avoid deg. jt disorders and articular collapse– Preserving ability to directly attach soft tissue

structures.

Disadv:– fatigue #, infection and non union at graft host

jxn.

Endoprosthetic ReconstructionEndoprosthetic Reconstruction

Long term fxn for some pts. Adv:

– Predictable immediate stability– Quicker rehab with immediate FWB– Increased durability – better implants.– Incremental limb lengthening

Disadv:– 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 prosthesisSegmental bone and joint prosthesis

Usually secured through composite fixation

Intramedullary 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 TECHNIQUESURGICAL TECHNIQUE

Upper ExtremityLower Extremity &Pelvis

Upper Extremity: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 girdleResection of shoulder girdle

Scapular tumors-– extend to glenohumeral jt.– Extra-articular resection of humeral

head en bloc with scapula

Proximal humeral tumors-– Extend into the joint through biceps

tendon– Extra-articular partial scapulectomy

Classification: 6 types.Classification: 6 types.

TYPE I – Intra-articular prox. humeral resection.

TYPE II – Partial scapular resection. Type III – Intra-articular total

scapulectomy. TYPE IV – Extra-articular total

scapulectomy and humeral head resection (Classical Tickhoff Linberg)

Malawer et al.

TYPE V –Extra-articular humeral head resection.

TYPE VI - Extra-articular humeral and total scapular resection.

Subtypes:– A - Abductor mech. intact.– B - Partial or complete resection.

Tikhoff- Linberg procedure:Tikhoff- Linberg procedure:

Total scapulectomyPartial/complete excision of clavicleExcision of prox. humerus.Use:–Malignant tumors about shoulder joint.– Usually sacrificing Axillary N. and

sometimes Radial N.

Resection of clavicle:Resection of clavicle:

Subcutaneous – early detection.Either end resection. Entire bone excision.Little loss of function.eg. solitary myelomas, ABC, non

specific granulomatous lesions.

Subtotal resection of scapulaSubtotal resection of scapula

Tumors of scapular body wihout joint involvement is rare.

E.g. Extraabdominal desmoids, GCT, Low grade Chondrosarcoma – Partial scapulectomy

Subscapularis m. good margin prevents chest wall invasion.

Partial resection of scapulaPartial resection of scapula

Parts of scapula to entire bone.E.g. Benign tumors, TB, chronic

ostemyelitis.Body alone resected – shoulder is

fairly stable and functional provided ms. are attached in fxnal positions.

Resection of proximal humerus:Resection of proximal humerus:

Biopsy - Anterior third of deltoid- no contamination of delto-pectoral interval.

Used in:– Sarcomas- Resection of prox. humerus

with contiguous soft tissues- satisfactory margins

– Aggressive benign neoplasms and metastatic carcinomas of prox. humerus.

Reconstructive alternatives:Reconstructive alternatives:

1. Flial shoulder

2. Passive Spacer – Allograft or autograft, fibular or prosthetic implants ( better cosmesis / fxn).

3. Arthroplasty (implant or allograft).

4. Arthrodesis e.g. Enneking method

Allograft arthrodesis is the most stable reconstuction for young pts. With vigorous activities.

Resection of distal humerusResection of distal humerus

Lesions in elbow requiring limb salvage are rare.

Occasional malignant/ aggressive benign lesions like Chondroblastoma or GCT.

Reconstruction options-– Flial elbow

– Osteaoarticular allograft– Implant arthroplasty– Arthrodesis

Resection of proximal radius / ulnaResection of proximal radius / ulna

Considerable portion can be resected without reconstruction in radius.

Resection of distal radius:Resection of distal radius:

E.g. GCT Reconstruction by: – Arthroplasty,– Arthrodesis using allograft or auto graft.

Proximal fibular auto graft reconstruction arthroplasty–Maintain motion but light activities.

Arthrodesis– Sacrifice motion but more stable.

Resection of distal ulnaResection of distal ulna

No reconstruction needed.Periosteum is excised with the

tumor.

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