Limb salvage

1. LIMB SALVAGE SURGERYLIMB SALVAGE SURGERY

2. Limb SalvageLimb Salvage
TRAUMA TUMOR

3. Limb salvage and traumaLimb salvage and trauma
Starts at E.R. when a mangled
extremity arrives – series of
decisions
1.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.

4. Most difficult decisionMost difficult decision
Whether to attempt salvage or not
5 Scoring systems published
Author / YearName Criteria
Gregory et al.1985
Mangled Extremity
Syndrome Index
9
Seiler et al.1986
- 4
Howe et al.1987
Predictive Salvage Index PSI4
Johansen et al.1990
Mangled Extremity Severity
Score (MESS)- Prospective
4
Russell et al.1991
Limb Salvage Index (LSI) 7

5. Mangled Extremity Severity ScoreMangled Extremity Severity Score

6. 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.

7. Relative indications of amputation in Relative indications of amputation in
Gustilo III-C tibial #sGustilo III-C tibial #sLange & 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.

8. 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.

9. 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.

10. TUMOR AND LIMB SALVAGETUMOR AND LIMB SALVAGE

11. 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

12. 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.

13. 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

14. LiteratureLiterature
Several 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.

15. Survival - No study has proved any
superiority of any surgical technique
comparing
–Limb salvage
–Transfemoral amputation or
–Hip disarticulation
Provided wide surgical margins
obtained.

16. AmputationAmputation
Technically demanding for
malignancy
–Non standard flaps
–Bone graft augmentation – better fxnal
limb
Complications
–Infection, wound dehiscence
–Chronic painful limb, phantom limb
–Appositional bone growth – revision.

17. Limb salvageLimb salvage
Greater perioperative and long term
morbidity.
–More extensive surgical procedure.
–Greater risk of infection & wound
dehiscence,
–Flap necrosis
–Blood loss
–DVT

18. Long term complications
–Periprosthetic fractures
–Prosthetic loosening or dislocation
–Non-union of graft-host junction
–Allograft #
–LLD & late infection
Multiple future operations.
1/3
rd
of long term survivors –
amputations.

19. 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.

20. Osteosarcoma around kneeOsteosarcoma around knee
Usually three surgical procedures
1.Wide resection with prosthetic knee
replacement,
2.Wide resection with allograft
arthrodesis &
3.Trans femoral amputation.
Less commonly,
–Osteoarticular allograft reconstruction
–Rotationplasty

21. 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

22. 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.

23. 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.

24. Allograft-prosthetic composite Allograft-prosthetic composite
reconstructionreconstruction
Location is important.
Proximal reconstruction generally
outlast more distal ones ( Inverse of
prognosis).
Prox. femoral > distal femoral > prox
tibial.

25. 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.

26. Psychological outcomePsychological outcome
No evidence of any significant diff.
Pt must make the final decision
–Short & long term goals
–Lifestyle modifications.

27. Margins of tumorMargins of tumor
Oncological surgical
procedures,
–margins should be
defined
–Amputation /
Resection.

28. Orthopedic oncologyOrthopedic oncology
Four terms
1.Intralesional
2.Marginal
3.Wide
4.Radical

29. Intralesional marginsIntralesional margins
Plane of dissection
is within the tumor,
Gross residual
tumor
Symptomatic
benign lesions
Debulking
Palliative
procedure in
metastatic disease.

30. Marginal marginMarginal margin
Closest plane of dissection passes
through the pseudocapsule.
Most benign lesions
Some low grade malignancies
Selective high grade malignancies
+ preop. radiotherapy and neoadjuvant
chemotherapy

31. Pseudocapsule
–contains
microscopic foci
of disease /
“satellite” lesions.
–Local recurrance
if not responding
to C.T. / R.T.

32. Wide marginsWide margins
Plane of dissection is
in normal tissue
No specific distance
defined.
Cuff of normal tissue
Goal of most
procedures for high
grade malignancies.

33. 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. *

34. 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).

35. 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.

36. 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.

37. 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.

38. 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.

39. 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.

40. 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.

41. 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.

42. SURGICAL TECHNIQUESURGICAL TECHNIQUE
Upper Extremity
Lower Extremity &
Pelvis

43. 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.

44. Resection of shoulder girdleResection of shoulder girdle
Scapular tumors-
–extend to glenohumeral jt.
–Extra-articular resection of humeral
head en bloc with scapula
Proximal humeral tumors-
–Extend into the joint through biceps
tendon
–Extra-articular partial scapulectomy

45. 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.

46. 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.

48. Tikhoff- Linberg procedure:Tikhoff- Linberg procedure:
Total scapulectomy
Partial/complete excision of clavicle
Excision of prox. humerus.
Use:
–Malignant tumors about shoulder joint.
–Usually sacrificing Axillary N. and
sometimes Radial N.

49. 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.

50. 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.

51. 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.

52. 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.

53. 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

54. Allograft
arthrodesis is the
most stable
reconstuction for
young pts. With
vigorous activities.

55. 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

56. Resection of proximal radius / ulnaResection of proximal radius / ulna
Considerable portion can be
resected without reconstruction in
radius.

57. 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.

58. Resection of distal ulnaResection of distal ulna
No reconstruction needed.
Periosteum is excised with the
tumor.

59. Thank You !