1. 1. CROUCHING TUMOUR HIDDEN SURGEON DR.R.PRABHA RAMKUMAR. MS ORTHOPAEDIC SURGERY EMAIL : dr.ramkumar23@gmail.com
2. 2. BEFORE Before the advent of chemotherapy and appropriate surgical techniques like CMP the prognosis of osteosarcoma was dismal. Most patients are treated with Wide or Radical amputation. But most patients died of distant metastasis (80%)
3. 3. AFTER With todays multiagent chemo and appropriate surgical techniques, long term survival of 60-70% for high grade without metastasis at initial presentation and 90% for low grade is possible.
4. 4. OUTCOME RESTS ON Extent of the disease Grade of the lesion Size of the primary lesion Site and location of the lesion (proximal>distal) Secondary metastasis 20% have at intial presentation Pulmonary and non pulmonary metastasis Time of diagnosis Resectable and Non resectable tumours Skip lesions same like metastasis Radiation induced Osteosarcomas (? Due to unusual unresectable sites)
5. 5. PROTOCOL 1 CLINICAL/RADIOLOGICAL EVALUATION 2 BIOPSY HISTOPAYHOLOGICAL CONFIRMATION 3 NEO ADJUVANT CHEMOTHERAPY 4 DEFINITIVE SURGERY 5 CHEMOTHERAPY AND REHABILITATION
6. 6. Clinical and radiological imaging A thorough Clinical and radiological evaluation is must Mainly to detect any occult metastasis which will affect the treatment outcome. Staging of the lesion and finding the lesion is intra or extra compartmental.
7. 7. Bone scan
8. 8. Biopsy and HPE examination Irrespective of imaging, a HPE diagnosis is of essence FNAC is not used as it offers less information Either a closed core biopsy or open biopsy is preffered Various complications related to open biopsy are large scale contamination of tissues, infection ,fracture Necrotic or heavily calcified or ossified areas are avoided
9. 9. Surgical METHODS Amputation/Disarticulation lesser post operative morbidity but poor functional outcome
10. 10. Limb Salvage-Wide excision with prosthetic augmentation or reconstruction with bone grafts has greater peri operative morbidity and good functional outcome. surgeries include -Resection and arthrodesis/arthroplasty -Resection with distraction osteogenesis -Resection and Prosthetic replacement/auto or allograft
11. 11. HOW TO DECIDE? If the tumor can be removed with an adequate margin and the resulting limb has satisfactory function -LIMB SALVAGE After salvage the limb should have an acceptable degree of function and cosmetic appearance with a minimal amount of pain, and should be capable of withstanding the demands of normal daily activities
12. 12. Four things to be considered , - Would survival be affected by the treatment choice? - How do short term and long term morbidity compare? - How do the function of a salvaged limb compare with that of prosthesis? - Are there any psycho social consequences?
13. 13. Amputation/ Disarticulation For larger tumours where recostruction and resection with wide margins not possible More proximal tumours As a palliative measure for distant metastasis and final stage for pain relief Level is according to the site of the tumour and extent Locally recurrent Pathological fracture where stabilisation not possible Malignancy with massive necrosis, fungation, infection or vascular compromise.
14. 14. our experience, 12 YEARS MALE
15. 15. Rt leg
16. 16. AFTER HIP DISARTICULATION
17. 17. LIMB SALVAGE- a guardian angel? Can be done by- -Wide excision and arthrodesis/arthroplasty - Wide excision with distraction osteogenesis - Wide excision and Prosthetic replacement. Studies shows no superiority of limb salvage to amputation. For successful outcome it is essential to achieve a complete resection of the tumor with an adequate margin(approx 3 cms from the extent from T1 MRI)
18. 18. 3 stages Excision of tumour Reconstruction of the defect Closure of the defect
19. 19. Excision of tumour If the joint is not contaminated by the tumor, an intraarticular resection is performed through the joint If the joint is involved-an extraarticular excision, taking the entire joint and joint capsule, and cutting through the uninvolved bone on the other side of the joint for a wide margin The gap remaining needs reconstruction either with metal or with bone or a composite of the two For tumors that involve the diaphyseal portion of a bone, an intercalary resection and reconstruction can be performed that saves the joints at either end.
20. 20. Good excision
21. 21. It is now possible to save the joint even if only 1.5-2cms of condyle thickness remain For low grade osteosarcoma, a hemicortical excision which removes only a part of the bone circumference is effective in disease control. The reconstruction done often depends on the kind of defect. Hemicortical defects result generally from partial circumferential excision of benign or low grade tumors like a parosteal osteosarcoma.
22. 22. Types of defects
23. 23. FILLING OF DEFECTS
24. 24. Reconstruction of resulting defect is must should allow effective closure Can be done with a bone ,a metal implant or a combo, Ilizarov using distraction osteogenesis is an alternative eliminate potential dead space and transfer tissues if necessary. Reconstruction or substitution of a segment of artery or nerve may be required. M/C site is the metaphysis so typical resection involves the whole proximal or distal part of the bone.
25. 25. Types of defects
26. 26. Joint involving large defects CUSTOM MEGAPROSTHESIS- Megaprosthesis is a large metallic joint designed to replace the excised length of bone and the adjacent joint. fully constrained hinge joints not affected by ongoing adjuvant treatment like chemotherapy and radiotherapy A customised joint has to be ordered as per individual patients dimensions takes 4-6 weeks for fabrication MODULAR PROSTHESIS - components are assembled.Allow for immediate availability, also allow intraoperative flexibility. The drawback is that they are expensive and a large inventory of the components has to be kept
27. 27. Currently modular systems are used for most adults and children near skeletal maturity as adequate modularity ensures a good fit into the defect for almost all patients. In children or in places where anatomy is distorted, customized implants are used to adjust for smaller or abnormal bone size and to allow expansion.
28. 28. custom mega prosthesis
29. 29. Pre op planning for CMP
30. 30. 45 years male
31. 31. Post op
32. 32. Modular prosthesis for distal femur
33. 33. EXPANDABLE PROSTHESIS- for Managing limb length in young children In children, the operated leg becomes shorter as the normal leg continues to grow while the operated leg does not resulted in limp and poor function could be lengthened periodically (expandable prosthesis). The prosthesis has a worm gear mechanism which allowed a telescoping cylinder to increase the length when a screw was turned Need periodical surgeries Newer implants allow lengthening by EM field to minimise surgeries
34. 34. OSTEOARTICULAR ALLOGRAFTS- have shown a success rate of 70% at long term follow-up have the advantage of providing biological bed for soft tissue anchorage. The attachment of muscle insertions is more successful in allografts than in prostheses, yielding better function in some sites Rather than a biologic replacement it acts as a biologic spacer. infection (5-15%), fracture (15-20%), Non-union (15- 20%) and osteoarthritis from collapse of the articular surface (with osteoarticular graft) can occur. Chemotherapy and radiotherapy can adversely affect the union rates
35. 35. ALLOPROSTHETIC COMPOSITE - combination of allo graft and endoprosthesis allograft is selected and implanted to replace the segment of bone resected. The articular surfaces of the graft are excised and replaced using conventional techniques of total joint arthroplasty provides a source of bone stock and a site for tendon insertions, while the prosthesis provides a reliable and stable articulation has a lower fracture rate than allograft alone and is not susceptible to osteoarthritis.
36. 36. RESECTION ARTHRODESIS- though disabling can provide a practical low cost option for reconstruction For pts engage in heavy manual labour, not easily accepted bone grafts coupled with internal fixation, very similar to those of intercalary resections. Autografts vascularised or nonvascularisedare used along with fixation which is either a locked long nail, or a long plate or sometimes an external fixator We have used a double barrel live fibula or an allograft combined with a live fibula and neutralized with a plate A non vascularised graft always has the risk of fracture
37. 37. Fixation is either with a plate spanning the defect or with a long customized nail Long time immobilisation
38. 38. ROTATIONPLASTY-allows the ankle to substitute as the knee after 180 degrees rotation of the limb Used in proximal focal femoral deficiency limb continuity is established by fusing the Tibia with the proximal femoral remnant functions like a below-knee amputation there is no phantom pain as sole is normal weight bearing area Psychological barrier
39. 39. Pt can run, ride a bike etc
40. 40. INTERCALARY DEFECTS Intercalary defects-classified as diaphyseal, metaphyseo-diaphyseal, or epiphyseodiaphyseal Intercalary allografts have shown higher success than the osteoarticular ones Vascularised fibula (VF) is a good alternative for intercalary defects especially for longer gaps. 93% union rate
41. 41. INTERCALARY DEFECTS Reimplantation of tumor bearing bone-Reimplanting the tumor bearing bone after some form of treatment (autoclaving, pasteurization, freezing with liquid nitrogen, or extracorporeal radiation) to kill the tumor cells is another exciting low cost option. Though dead like an allograft, it is perfectly matched to the defect 12 cases from Pakistan showed good with only one non- union High temperatures can cause bone weakening hence Pasteurisation ( heating the bone to 60 deg C for 30 min in a water bath ) is preferred Extracorporeal irradiation is equally effective
42. 42. Reimplantation after radiation
43. 43. INTERCALARY DEFECTS PROSTHESIS- also be used to reconstruct non-joint defects can be used as physis sparing or joint saving implants avoids the donor site morbidity of autograft and the fracture and non-union risk of allograft especially for patients on chemotherapy shortens surgical time compared to grafting higher rate of loosening is due to rotational stress aseptic loosening may be reduced with hydroxyapatite (HA) or porous titanium bead coating
44. 44. INTERCALARY DEFECTS
45. 45. OUR EXPERIENCE , 14 years male
46. 46. DIATRACTION OSTEOGENESIS
47. 47. OSTEOSARCOMA OF PELVIS challenge to an orthopaedic oncologist Tumors are often large at presentation and do not always respond well to the preoperative chemotherapy The surgery is extensive and has the potential for many complications. An external hemipelvectomy has therefore been the standard of care in the past Though it causes major disfigurement and extensive functional handicap, it was the safest way of getting a chance of cure in a pelvic osteosarcoma
48. 48. Limb saving resections have now become feasible and are the standard of care. Pelvic resections are any one or the combination of the following four types Type I (Iliac), Type II (periacetabular), Type3 (anterior arch) and typeIV (sacrum) internal hemipelvectomy- resection of the entire hemipelvis from the SI joint to the pubic symphysis. Today, the term has come to include resections of the pelvis which include the acetabulum with varying portions of the Ilium & the anterior arch
49. 49. Resections involving the acetabulum leave behind significantly more instability than the other types of partial pelvic resections. reconstruction using -arthodesis (iliofemoral and ischiofemoral fusion), - surgical pseudarthrosis (mesh reconstruction), -pelvic allografts, - custom-made endoprostheses, the saddle prosthesis - reimplantation of the excised hemipelvis after sterilisation by radiation have been used with better cosmetic and functional results
50. 50. Tumors located near the sacroiliac joints or pubic symphysis present a special problem in that positive margins of resection may occur unless the procedure is extended to the sacral ala or the contralateral side of the symphysis, respectively Induction chemotherapy may be useful to shrink these tumors prior to their surgical removal
51. 51. Ilio femoral fusion
52. 52. Reconstruction by custom acetabular prosthesis
53. 53. Our experience, 22 years male
54. 54. Hemipelvectomy x ray
55. 55. Limb salvage-disadvantages Limb salvage is a more extensive surgical procedure with increased the risk of - Infection - wound dehiscence and flap necrosis - Blood loss - DVT - local recurrence - peri prosthetic fractures/ implant loosening -Graft host rejection -Allograft fracture - Leg length discrepancy - multiple subsequent surgery But Despite of all this it has better post operative functional outcome.
56. 56. Final word ideal situation is when the disease can be successfully removed without an amputation and the resulting loss of bone and muscle compensated by a method which retains near normal limb function. Patient survivals have dramatically improved following the availability of newer chemotherapy drugs and this has accentuated the need for durable methods of reconstruction of large musculoskeletal defects Ever increasing advances in technology and biomaterials combined with a better understanding of biomechanics will further help in increasing the durability of and refining limb salvage procedures
57. 57. THANK YOU