LIMB SALVAGE SURGERY Dr Dharma Ram PooniaRGCI & RC08.06.2016

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• DEFINITION AND INTRODUCTION• PATIENT SELECTION • HISTORICAL BACKGROUND• SURGICAL PRINCIPLES stage 1 to 3• INDIVIDUAL SITES• COMPLICATION AND SURVIVAL• FUTURE • SUMMARY

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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

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PATIENT SELECTION

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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 5

• 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

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Functional outcome & QOL : COMPARABLE

Oncological outcome: superiority

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• 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. 8

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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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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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

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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 contraindicationMetastatic disease too is not contraindication

Pan compartmental, fungating growthDisplaced #, not healed after chemo

MALAWER 2009

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BoneNervesVesselsSoft 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 anymore13

SURGICAL PRINCIPLES

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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 15

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. 16

Skeletal Defects

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Joint involving defects : Stage II

1. Resection arthrodesis

2. Osteoarticular allograft recon

3. Mega prosthesis

• Expandable prosthesis

4. Allograft Prosthetic composite (APC)

5. Rotationoplasty18

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 19

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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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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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 22

Techn.

aspects

• 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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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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Endoprosthetic ReconstructionAdvantage

• 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 loosening25

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 practice26

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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• 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

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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

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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 31

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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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. 33

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.

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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/ Psedoprosthesis35

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. 36

b. Proximal & Total Femur

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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

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d. Proximal tibia 1. proximal tibia skin necrosis prone

2.

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e. Pectoral resection

• Flail shoulder

• Passive Spacer – Allograft

or autograft, fibular or

prosthetic implants ( better

cosmesis / fxn).

• Arthroplasty (implant or

allograft).

• Arthrodesis

Allograft arthrodesis

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• 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.

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• 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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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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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

• Rotationoplasty44

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. 45

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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116 LSS by Nov 2012 Patients of osteosarcoma 51 Reported results of OS onlyOS3 66%EFS3 61.8%Best functional score with proximal& distal femur, least with Knee arthrodesis

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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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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

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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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Thank you.

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