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Tumor, limb salvage, hip and knee
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RECONSTRUCTIVE SURGERIES OF RECONSTRUCTIVE SURGERIES OF TUMORS AROUND HIP AND KNEE JOINT TUMORS AROUND HIP AND KNEE JOINT (LIMB SALVAGE SURGERIES)(LIMB SALVAGE SURGERIES)
Dr. Sushil Paudel
History of limb salvage surgeryHistory of limb salvage surgery
Lexer – 1st successful series of 6 pts.
Concept of using allografts in tumor surgery – Lexer
1907
Barggreve : First described rotationplasty in 1930 for TB of limbs
Kristen Knahr and Salzer in 1975 used rotationplasty in osteosarcoma of distal femur
Definition of limb salvage surgeryDefinition of limb salvage surgery
A set of surgical techniques that have been developed to restore the skeletal continuity following the enbloc resection of bone and soft tissue neoplasm
Goal of limb salvage surgery : Painless limb Functional, tumor free limb
Why limb salvage surgery ?Why limb salvage surgery ?
Before 1970: 5 years survival 10-20% in osteosarcoma and Ewing sarcoma.
Now 5 years survival 65-75% Limb salvage surgery possible 90%
cases Reasons: Chemotherapy
Better diagnostic facilities
Improved and well defined
Surgical technique{OCNA 1991}
Preoperative evaluation Preoperative evaluation Biopsy : first step in reconstructive surgeries Type of biopsy :
Core biopsy (Preferred) Open biopsy: Incisional (Preferred)
Excisional Site :
Proximal femur : Lateral approach Distal femur: Anterior approach
Lateral approach Proximal tibia: Medial at flare of metaphysis
Biopsy
Principles of biopsy Principles of biopsy
Longitudinal incision
Violate only one compartment
Muscles are split
Done by same surgeon in same institute
Avoid joint contamination
Soft tissue element best for biopsy.
Osteosarcoma
Plain X-ray Affected bone and joint
Chest X-ray
Skeletal survey
MRI: Investigation of choiceSoft tissue extent
Skip lesion
Vascularity of tumor
Neurovascular involvement
Radiological investigations
CT Scan
Cortical involvement
Soft tissue calcification
CT chest: Metastasis
Bone Scan Tc99- metastasis
Angiography (DSA)
Vascularity of the tumor ,donor and recipient site in microvascular reconstructive surgery
Radiological investigations(contd..)
MRI DSA
Staging of tumor Staging of tumor Enneking system : Benign tumor : Latent
Active Aggressive
Malignant tumor
Stage Grade Site Metastasis
IA G1 T1 M0IB G1 T2 M0IIA G2 T1 M0IIB G2 T2 M0III G1-2 T2 M1
AJCC system :AJCC system : Tumor size Grade Depth Metastasis Low grade Well differentiated (metastasis <25%) Few mitosis Moderately cytological atypia High grade Poorly differentiated High mitotic stage High cell/matrix ratio.
Psychosocial and Psychosocial and functional evaluationfunctional evaluation Musculoskeletal tumor society functional
score.• Pain, function, acceptance,gait.
Short form 36.Toronto extremity salvage score.
Role of chemotherapy and Role of chemotherapy and radiotherapy radiotherapy
Neoadjuvant Adjuvant Indication : High grade tumor
Low grade tumor Advantages of neoadjuvant chemotherapy
Prevent development of drug resistance Prevent micrometastasis Reduce size of tumor Measure effectiveness of chemotherapy
Allow planning of surgery and procurement of implant
Regimen of chemotherapy of osteosarcoma: Regimen of chemotherapy of osteosarcoma: AIIMS Protocol AIIMS Protocol
Multiagent neoadjuvant chemotherapy: 1. CAMP regimen
3 cycles at 3 week interval 2. ICE regimen
3. High dose methotrexate
Follow up: HPE > 90% necrosis Clinical and radiological re-evaluation after chemotherapy
Operate after 12-13 week Wound healing for 3 weeks
Continue adjuvant chemotherapy 3 weekly x 40 weeks
T10 regime : (Sloan Ketring cancer centre)
Combination of - high dose methotrexate, leucovorin, CDDP, BCD.
Radiotherapy :
Osteosarcoma - No definitive role
Ewing sarcoma
Chemotherapy: Vincristine, cyclophosphamide, actinomycin, ifosfamide.
Radiotherapy : 30-40G to whole bone and Booster to primary tumor with two doses of 50-55G.
Chemotherapy plus Radiotherapy
Surgical margin
Limb salvageLimb salvage
Combines two procedures-
Wide resection
Reconstruction of skeletal defect
Survival and local recurrence depends on
margins achieved during resection and not on
method of reconstruction
IndicationIndication
Every patient with tumor of the extremity should be
considered for limb salvage if the tumor can be
removed with an adequate margin and the resulting
limb is worth saving
No justification for limiting the limb salvage process
based only on the prognosis
Salvaged limbSalvaged limb
Acceptable degree of function
Cosmetic appearance
Minimal amount of pain
Durable enough to withstand the
demands of normal daily activities
ContraindicationsContraindications Neurovascular involvement Large size tumour Displaced pathologic fracture(relative contraindication) Fungating and infected tumors Recurrence of malignant tumors Skeletal immaturity - 60% growth occur through distal
femoral and proximal tibial epiphysisPulmonary metastasis is not a contraindication
of surgery Contraindications of limb salvage are the indications for amputation
ContraindicationsContraindications
Three strike rule Bone Nerves Vessels Soft tissue envelope
If three of these key components are involved, the limb salvage is probably not worth considering
Principles & TechniquesPrinciples & Techniques
Resection of tumor – Principles of surgical oncology
Skeletal reconstruction – Principles of orthopaedic surgery
Soft tissue & muscle transfer – Principles of plastic surgery
Resection of tumor : Intra articular Extra articular
Margin 5-7 cm *Adherent neurovascular bundles - amputation Surgical margin - near neurovascular bundle
(* OCNA JAN 91)
KNEE
Methods of ReconstructionMethods of Reconstruction
Arthrodesis Mobile joint reconstruction Osteoarticular allograft Endoprosthetic replacement Allograft Endoprosthetic composite Rotationplasty Autoclaved tumor bone
Arthrodesis of hipArthrodesis of hip
Advantage : Physically active life
Failure are less
Disadvantage : Loss of motion : no functional limitation Difficult to position the extremity for arthrodesis Long healing time
Arthrodesis of hip (contd.) Technique : Fusion of proximal femur to ilium / ischial
tuberosity with or without intercalary graft If gap <6-8 cm: No intercalary allograft >6-8 : allograft
Allograft with head : Fixed with long screw to pelvis and to femur - cobraplate / DCP
Postoperative : Hip spica
ARTHRODESIS OF HIP
Arthrodesis of kneeArthrodesis of knee
Young adult patient Knee arthrodesis using regional autograft
Enneking and Shirley Dual fibular graft
Using allograft+ intramedullary nail Using intercalary allograft with plate and screw
Postoperative Postoperative
TURN O PLASTY
TURN O PLASTY
RECONSTRUCTION USING BONE GRAFT
Non-articular (Intercalary)
Articular reconstruction
Autograft
Allograft
Non-articular(Autogenous) graftAdvantage : Hypertrophy and no immune rejection
Disadvantage : Limited source and donor site morbidity• Sources : Fibula, Iliac crest and tibia
Enneking - Compensatory hypertrophy 32% In fibular graft (Atrophy 9%)
Zwierzchowski - Ideal for children (OCNA JAN 91)
Non-articular(Autogenous) graft
Vascularized fibular graft :
Advantage: No creeping substitution Heal in hostile environment(Irradiated tissue and active infection) Healing within 6 months
Disadvantage : Technically demanding Long operative time
Osteoarticular graft (Allograft) :
To restore anatomy and physiology of near normal joint
Advantages : Length can be adjusted
Biological soft tissue healing
Avoid the risks and complications of intramedullary fixation of endoprosthesis
Direct attachment of remaining musculature
Disadvantage Long healing times
Potential for transfer of disease and infection
Immune rejection
Necessity of articular surface size matching
Fracture
Infection
Non union
Osteoarticular graft (Allograft)(contd.) :
Technique
Size
Trial for reduction : should produce suction when being dislocated - negative – alloendoprosthesis
Fixation with plate on anterolateral surface
Abductor attached to graft
Postoperative
Restrained exercise - 6 weeks
Strengthening exercise - 8 weeks
Weight bearing - 12 months
Osteoarticular graft (distal femur)
Large graftRigid fixation to host bone with plate on lateral and anterior
surface of femur (entire length) Reconstruction of posterior capsule, collateral and cruciate
ligaments with nonabsorbable suture (heavy)Unicondylar arthroplasty : Stage 3 or IA
• Patella graft • Vascularized fibula
Postoperative : Full weight bearing after one year
Reconstructions using autoclaved Reconstructions using autoclaved bone graftbone graft
Proximal tibialProximal tibial
Limb salvage is difficult
Proximity to knee joint
Poster lateral position of neurovascular bundles
Lack of Adequate soft tissue
Difficulty of reattachment of patellar tendon after resection - principle challenge
Proximal femoral endoprosthesis
Oldest, widely used method
Treatment of choiceTreatment of choice of patient with limited life expectancy
Type of endoprosthesisBipolar THR:
Short stem Long stem
Proximal femoral endoprosthesisAdvantage
No prolong protected weight bearing Good ambulatory gait No risk of transmission of disease / infection
Disadvantage Mechanical failure Loosening Stress fracture
Proximal femoral endoprosthesis14-18 mm diameter : Age, Size of patient and
Diameter of femur Length 135-200mmAnterior bow
Modular prosthesis : Extramedullary porous in growth material on the segment proximal to stem.
Trial in reduction
Postoperative Hip spica Instability during surgery : Abduction brace : 2-3 months
Proximal femoral replacement – problems
Instability Dislocation – 2% - 14% Loosening of acetabular component -46% Aseptic loosening of femoral component Functional outcome limited due to poor abductor function Infection 0-14%
Yavuz kabuet et al CORR 91
Seminar on surgical oncology (1997)13:3-10
Segmental custom made total knee replacement
Indications Primary malignant tumor Metastatic tumor Stage three begin tumor
MODULAR CUSTOM MADE KNEE JOINT
Segmental custom made total knee replacement
Advantage Immediate stability Early mobilization and weight bearing
Disadvantage Mechanical failure Stress fracture Failure of fixation to host bone Limited ability to change the size intraoperatively Time delay in the procurement of implant Expensive
Prosthesis Rotating hinge knee Flexion and extension and axial rotation Size and length Femoral stem 130-155mm
Postoperative Flexion - 90° and full extension 6 month - normal gait without aid
Distal femoral prosthetic replacement
Overall survival 5yrs - 80%
10yrs - 65%20yrs - 53%
Unwin et al:J.Arthroplasty:8:259-68 (1993)
Rotating hinge prosthesis -90% 5 yrs.survival
Proximal tibial prosthetic replacementProximal tibial prosthetic replacement
Limitations due to poor native soft tissue coverage Unreliable option for ext.mechanism reconstruction 5 yrs. survival - 45%-74% 10 yrs.survival - 45%-53%
Infection upto 31% Wound complication upto 38%
Malawer et al-J.B.J.S.(A) 77A:1154-1165.1995
Alloprosthesis Endoprosthesis fixed to a allograft rigidly fixed with host
boneHIP: Indication: If allograft does not fit into acetabulum
Inadequate acetabular articular cartilage
KNEE:Indication :Removal of most or all ligamentous structure around knee Proximal tibia resected with distal femur but extensor mechanism
saved
Younger patients Younger patients
Rotation plasty : Act like a below knee amputation
Expandable prosthesis
Arthrodesis of hip
Rotation plasty Borggreve : First described in 1930 for TB of limbs
Kristen : Knahr and Salzer in 1975 used in osteosarcoma of distal femur
<10 year with removal of distal femoral epiphysis with tumor
Sciatic nerve to be preserved
Winkelmann classified rotation plasty in five groups
• Group AI : Lesion in distal femur
• Group AII : Lesion in proximal tibia
ROTATIONPLASTY
AII
BI
BII
BIII
AI
Rotation plasty
Group BI : Lesion in the proximal femur sparing the hip joint and gluteal muscles
Group BII : Lesion in proximal femur with involvement of hip joint and adjacent soft tissue
Group BIII: Lesion mid femur
Postoperative : Single hip spica
Expandable prosthesis :
Hollow titanium tube assembled over a threaded shaft and fitted with a adjustable ring.
Lengthening : -1 to 2 cm at a time
Soft tissue reconstruction HIP-CapsuleAbductor
Reattatched to endoprosthesis or allograft 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
Extensor mechanism KNEE JOINTPatellar tendon reattachment Pes anserinus / semimembranosus
Soft tissue reconstruction Medial gastrocnemius flap Advantage :
• Cover the prosthesis • Suturing of patellar tendon and capsule to muscle
Disadvantage : • Bulk of leg increases • Split thickness graft • Rehabilitation only after 3-4 week • Extension lag 70-90°
Outcome after limb salvage surgeryOutcome after limb salvage surgery
No difference in psychological,physical function, survival, disease free interval.
Irwin et al: JBJS 72A;90
A/k amputation
Disarticulation
Limb salvage
Local recurrence
9%
-
8%
Reoperation
10%
2%
30%
Functional score
19%
16%
23%Bruce T. Rougraft et al: JBJS 1994
surgery
ConclusionConclusion
Limb salvage has become accepted standard care of
the pt’s with malignant bone tumors
Success depends on prompt detection and early
referral by primary care doctor and on careful and
coordinated sequences of events
Achieving a surgical margin that will ensure a low rate
of local recurrence is paramount
A variety of techniques are available
KEEP CONFERENCE HALL
CLEAN
PLEASE DISPOSEEMPTY BOXES
OUTSIDE THE HALL