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 decisions1. 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 - 4Howe et al.1987 Predictive Salvage Index PSI 4Johansen et al.1990 Mangled Extremity Severity
Score (MESS)- Prospective4
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
limbComplications
– 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 scapulaProximal 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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