WELCOME LECTURE

dr. Rizki Rahmadian

“ mimpi adalah kunci untuk kita menaklukan dunia, berlarilah tanpa lelah sampai engkau

meraihnya”

nidji

Limb Salvage Surgery for Extremity Bone Sarcoma

Amputation

Introduction

• Concept of limb salvage surgery 25 years

• 1970s adriamicyn & MTX

• Ralp Marcove, Kenneth Francis & Hugh Watts limb salvage surgery technique

Introduction

Today 90-95 % patient with extremity sarcoma who are treated at major centers specializing in

musculoskeletal oncology can undergo limb-sparing surgery procedures

Introduction

This dramatic alteration :

1. Improved understanding of tumor biology;

2. Effective induction chemotherapy;

3. Technical advances in surgical techniques;

4. Better characterization of the biomechanics of the human

skeleton;

5. Advanced material engineering and manufacturing

techniques;

6. The development of a reliable, stable modular prosthesis

for reconstruction of the hip, shoulder, and knee.

Early Management & Referral

• A successful limb salvage depends on :– A well - coordinated and timely series the

first physician to see the patient

– History and general examination

– The basic work-up should include high quality plain radiographs for bone lesions.

Early Management & Referral

Biopsy is not a part of the initial management of these lesions and is usually the last step in the

work-up.

The biopsy should be performed by the surgeon who will be doing the definitive

surgery.

Work-up

• Multidisciplinary team : – Orthopedic oncologist– Medical oncologist– Radiation oncologists– Musculoskeletal radiologist– Pathologist– Clinical psychologist– Social worker

CLINICO PATHOLOGICAL CONFRENCE

Staging

• The basic staging work : – High quality plain radiographs– Magnetic resonance imaging

study of the entire tumor and nearby anatomic structures

– Computed tomography scan of the chest

– Whole body technetium bone scan– Biopsy of the tumor

Work-up

The biopsy site must be carefully planned and located along so-called

“limb—salvage lines”

Biopsy

Drain Placement

Staging

Patient Education

The patient and the patient’s family should be given the opportunity to

participate in the decision

Indication

• Every patient with a malignant tumor of the extremity should be considered for limb salvage.

• The patient’s prognosis has a limited impact on the decision to perform limb salvage surgery.

• In selected cases, limb salvage can be combined with metastasectomy.

Indication

• Minimum morbidity and rapid return to function.

• Patients can enjoy relief from pain, improved quality of life, and intact body image that limb salvage can offer, even if they may not survive long-term.

Barriers

Barriers to limb salvage include – Poorly placed biopsy incisions, – Major vascular involvement, – Incasement of a major motor nerve,– Pathological fracture of the involved bone,

and others.

These adverse factors should not be viewed as absolute contraindications.

STAGES OF LIMB-SPARING SURGERY

Limb-sparing procedure can be divided into five stages :

• Neoadjuvant chemtherapy• Tumor resection must spare significant

structures.• Stable, painless skeletal reconstruction• The surrounding and supporting soft tissue• Adjuvant chemotherapy

Huvos Tumor Necrosis Grading System

Surgical Resections and Reconstructions

• The cornerstone of a limb salvage procedure is a complete resection of the tumor with an adequate margin.

• Margins can be defined as intralesional, marginal, wide, and radical

Surgical Resections and Reconstructions

• After completion of the tumor resection, the surgeon must reconstruct the resulting surgical defect.

• The excised segment of bone must be replaced– Large internal prosthesis, – Segment of allograft bone, – Composite of an allograft and a prosthesis– Other methods.

Resection Arthrodesis

Resection Arthrodesis

Osteoarticular Allograft

Endoprosthesis

Endoprosthesis

Expandeble endoprosthesis

Case

• Survival : 5 yaers survival rate 40 -70 %, local recurrence : 5 -10 %

• Immidiatete and Delayed Morbidity : increase revision

• Function : better than amputation

• Psycosocial Benefits : gooad early psycosocial adjustment

Thank you