Definition of neoplasia, classification of bone tumors, and principle of limb salvage

1. HYPERPLASIA, METAPLASIA, ANAPLASIAHYPERPLASIA, METAPLASIA, ANAPLASIA
NEOPLASIA, TNM CLASSIFICATION AND ITSNEOPLASIA, TNM CLASSIFICATION AND ITS
ORTHOPAEDIC APPLICATIONS, SURGICALORTHOPAEDIC APPLICATIONS, SURGICAL
CLASSIFICATION, HISTOLOGICCLASSIFICATION, HISTOLOGIC
CLASSIFICATION AND PRINCIPLES OF LIMBCLASSIFICATION AND PRINCIPLES OF LIMB
SALVAGE SURGERYSALVAGE SURGERY
Dr. Sushil PaudelDr. Sushil Paudel

2. NEOPLASIANEOPLASIA
 A neoplasm is anA neoplasm is an
abnormal mass ofabnormal mass of
tissue, growth oftissue, growth of
which exceeds & iswhich exceeds & is
uncoordinated withuncoordinated with
that of the normalthat of the normal
tissues **tissues **
**Willis RA; The spread of tumours in the human body.
London, Butterworth & Co, 1952

3. HYPERPLASIAHYPERPLASIA
 Increase in the number of cells in an organIncrease in the number of cells in an organ
or tissueor tissue
Physiological hyperplasiaPhysiological hyperplasia
Pathological hyperplasiaPathological hyperplasia

4. METAPLASIAMETAPLASIA
 Reversible change in which one cell typeReversible change in which one cell type
(epithelial or mesenchymal) is replaced by(epithelial or mesenchymal) is replaced by
anotheranother
Epithelial metaplasiaEpithelial metaplasia
Connective tissue metaplasiaConnective tissue metaplasia
Eg; Myositis ossificansEg; Myositis ossificans

5. DIFFERENTIATION ANDDIFFERENTIATION AND
ANAPLASIAANAPLASIA
 Anaplasia is loss of DifferentiationAnaplasia is loss of Differentiation
PleomorphismPleomorphism
Altered N:C ratioAltered N:C ratio
Atypical mitosesAtypical mitoses
Tumor giant cellsTumor giant cells

6. DYSPLASIADYSPLASIA
 Disordered growthDisordered growth
 Loss in the uniformity of individual cells asLoss in the uniformity of individual cells as
well as loss in architectural orientationwell as loss in architectural orientation

7. CLASSIFICATION OF BONE
TUMORS

8. HISTORYHISTORY
 Dates back to 1920, origin of Bone SarcomaDates back to 1920, origin of Bone Sarcoma
Registry by Dr CodmanRegistry by Dr Codman
 Dr Codman along with James Ewing andDr Codman along with James Ewing and
Bloodgod drew up in 1922, the first classificationBloodgod drew up in 1922, the first classification
of the Registryof the Registry
 Efforts of many pathologists and oncologists hasEfforts of many pathologists and oncologists has
given shape to Revised WHO Histologicgiven shape to Revised WHO Histologic
Classification of Bone tumours in 1993**Classification of Bone tumours in 1993**
**Schajowicz etal,Cancer 1995 Mar

9. Primary tumour (T) TX: primary tumour cannot be assessed
T0: no evidence of primary tumour
T1: tumour 􀀩 8 cm in greatest dimension
T2: tumour > 8 cm in greatest dimension
T3: discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX: regional lymph nodes cannot be assessed
N0: no regional lymph node metastasis
N1: regional lymph node metastasis
Note: Regional node involvement is rare and cases in which nodal status is not
assessed either
clinically or pathologically could be considered N0 instead of NX or pNX.
Distant metastasis (M) MX: distant metastasis cannot be assessed
M0: no distant metastasis
M1: distant metastasis
M1a: lung
M1b: other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION

10. Translation table for ‘three’ and ‘four grade’ to ‘two grade’ (low vs. high grade)
system
TNM two grade system Three grade systems Four grade systems
Low grade Grade 1 Grade 1
Grade 2
High grade Grade 2
Grade 3 Grade 3
Grade 4
Note: Ewing sarcoma is classified as high grade.
Stage IA T1 N0,NX M0 Low grade
Stage IB T2 N0,NX M0 Low grade
Stage IIA T1 N0,NX M0 High grade
Stage IIB T2 N0,NX M0 High grade
Stage III T3 N0,NX M0 Any grade
Stage IVA Any T N0,NX M1a Any grade
Stage IVB Any T N1 Any M Any grade
Any T Any N M1b Any grade
HISTOPATHOLOGICAL GRADINGHISTOPATHOLOGICAL GRADING

11. BenignBenign
 LatentLatent
 ActiveActive
 AggressiveAggressive
MalignantMalignant
 Stage IA-Low grade,Stage IA-Low grade,
intracompartmentalintracompartmental
 Stage IB-Low grade,Stage IB-Low grade,
extracompartmentalextracompartmental
 Stage IIA-High grade,Stage IIA-High grade,
intracompartmentalintracompartmental
 Stage IIB-HighStage IIB-High
grade,extracompartmentalgrade,extracompartmental
 Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING

12. WHO HISTOLOGICALWHO HISTOLOGICAL
CLASSIFICATIONCLASSIFICATION
 Osteogenic tumoursOsteogenic tumours
 Cartilage tumoursCartilage tumours
 Fibrogenic tumoursFibrogenic tumours
 Round cell lesionsRound cell lesions
 Giant cell tumour of boneGiant cell tumour of bone
 Notochordal tumoursNotochordal tumours
 Vascular tumoursVascular tumours
 Smooth muscle tumoursSmooth muscle tumours
 Lipogenic tumoursLipogenic tumours
 Neural tumoursNeural tumours
 Miscellaneous tumoursMiscellaneous tumours
 Joint lesionsJoint lesions
Each class is further divided into benign and malignantEach class is further divided into benign and malignant

13. BONE FORMING (Osteogenic)BONE FORMING (Osteogenic)
LESIONSLESIONS
BENIGN LESIONSBENIGN LESIONS
 OsteomaOsteoma
 Enostoses (Bone island)Enostoses (Bone island)
 Osteoid osteomaOsteoid osteoma
 OsteoblastomaOsteoblastoma

14. MALIGNANT LESIONSMALIGNANT LESIONS
 OSTEOSARCOMASOSTEOSARCOMAS
share the ability to form osteoid from theshare the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
 Takes into account etiology, localisation,Takes into account etiology, localisation,
bone specific topography and histologybone specific topography and histology

16. PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS

INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
 INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
 SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
 EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA

17.  INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1. INTRAMEDULLARY1. INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid

18.  IMAGINGIMAGING
Medullary and cortical bone destruction , aggressive periosteal reaction of the velvet
and sunburst types, soft tissue mass contains tumor bone.

19.  HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid

20. 2.MALIGNANT FIBROUS HISTIOCYTOMA2.MALIGNANT FIBROUS HISTIOCYTOMA
LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3.GIANT CELL RICH OSTEOSARCOMA3.GIANT CELL RICH OSTEOSARCOMA
4.SMALL CELL OSTEOSARCOMA4.SMALL CELL OSTEOSARCOMA
5.LOW GRADE CENTRAL5.LOW GRADE CENTRAL
OSTEOSARCOMAOSTEOSARCOMA

21. 6.TELANGIECTATIC OSTEOSARCOMA6.TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive andAggressive and
poor prognosispoor prognosis

22. 7.GNATHIC OSTEOSARCOMA7.GNATHIC OSTEOSARCOMA
8.MULTIFOCAL OSTEOSARCOMA8.MULTIFOCAL OSTEOSARCOMA
9. OSTEOSARCOMAS WITH UNUSUAL9. OSTEOSARCOMAS WITH UNUSUAL
CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome, Li fraumeni syndrome,Werner syndrome, Li fraumeni syndrome,
Blooms syndrome, RetinoblastomaBlooms syndrome, Retinoblastoma
syndromesyndrome

23. SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT ?
POST IRRADIATION

24. CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS
 CHONDROMACHONDROMA
EnchondromaEnchondroma
Periosteal chondromaPeriosteal chondroma
Enchondromatosis –Enchondromatosis –
Olliers disease, Mafucci syndromeOlliers disease, Mafucci syndrome
Soft tissue chondromaSoft tissue chondroma

25.  OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditaryMultiple hereditary
osteochondromataosteochondromata

26.  CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred site– epiphysisPreferred site– epiphysis
 CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
 SYNOVIALSYNOVIAL
OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS

27. MALIGNANT TUMOURSMALIGNANT TUMOURS
 CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with
annular and comma shaped calcifications and
periosteal new bone formation

28.  CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
 MESENCHYMAL CHONDROSARCOMAMESENCHYMAL CHONDROSARCOMA
 MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
 DEDIFFERENTIATED CHONDROSARCOMADEDIFFERENTIATED CHONDROSARCOMA
 PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
 SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
 EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA

29. SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED

30. FIBROGENIC, FIBROOSSEOUS ANDFIBROGENIC, FIBROOSSEOUS AND
FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECT
AND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTIC
POLYOSTOTIC
MC CUNE ALBRIGHT SYNDROME
MAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA
(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA

31. FIBROSARCOMA AND
MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets disease
Fibrous dysplasia
Bone infarct
Chronic sinuses of osteomyelitis

32. ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL
HISTIOCYTOSIS
Eusinophilic granuloma
Hand Schullers Christian disease
Letterer Siwe disease
Vertebra plana

33. MALIGNANT LESIONSMALIGNANT LESIONS
 EWINGS SARCOMAEWINGS SARCOMA
Diaphysis of long bonesDiaphysis of long bones
 MALIGNANT LYMPHOMAMALIGNANT LYMPHOMA
Non hodgkins lymphomaNon hodgkins lymphoma
Hodgkins lymphomaHodgkins lymphoma
permeative bone destruction
with an aggressive periosteal reaction

34.  MYELOMAMYELOMA
(Plasmacytoma)(Plasmacytoma)
Most commonMost common
primary malignantprimary malignant
tumourtumour
TYPES

35. VASCULAR LESIONSVASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA

36. MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA

37. UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOUR
BENIGNBENIGN
20-40 yr, F>M20-40 yr, F>M
Epiphyseal region ofEpiphyseal region of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent, eccentric, expansive,
absence of reactive sclerosis

38. MISCELLANEOUS TUMORS ANDMISCELLANEOUS TUMORS AND
TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN
 SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal, central, lack of periosteal reaction

39.  ANEURYSMAL BONEANEURYSMAL BONE
CYSTCYST
<20 yr, F>M<20 yr, F>M
Metaphysis of long bonesMetaphysis of long bones
 SOLID VARIANT OFSOLID VARIANT OF
ANEURSYMAL BONEANEURSYMAL BONE
CYSTCYST
Giant cell reparativeGiant cell reparative
granulomagranuloma
Radiolucent, eccentric, expansive,
butress of periosteal reaction

40. MALIGNANT LESIONSMALIGNANT LESIONS
 ADAMANTINOMAADAMANTINOMA
 CHORDOMACHORDOMA
 LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE

41. rr
OSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL

42. PRINCIPLES OF LIMB SALVAGEPRINCIPLES OF LIMB SALVAGE
SURGERYSURGERY

43. DEFINITIONDEFINITION
** HENRY DEGROOT et al, LIMB SALVAGE FOR EXTREMITY SARCOMAS** HENRY DEGROOT et al, LIMB SALVAGE FOR EXTREMITY SARCOMAS
A set of surgical procedures designed to accomplish
removal of a malignant tumor and reconstruction of
the limb with an acceptable oncologic, functional, and
cosmetic result**

44. HISTORY AND CHANGINGHISTORY AND CHANGING
TRENDTREND
 Eiselberg in 1897Eiselberg in 1897
 LexerLexer  11stst
successful series of 6 patientssuccessful series of 6 patients
 LexerLexer  concept of using allografts in tumor surgeryconcept of using allografts in tumor surgery
(1907)(1907)
 Major changes since 1970 with the advent of advancedMajor changes since 1970 with the advent of advanced
imaging, chemotherapy and radiotherapy, improvedimaging, chemotherapy and radiotherapy, improved
surgical techniquessurgical techniques
 Limb salvage possible in up to 85% cases**.Limb salvage possible in up to 85% cases**.
**Bacci G, Picci 2, Pignatti G,etal**Bacci G, Picci 2, Pignatti G,etal

45. INDICATIONINDICATION
 Every patient with tumor of the extremityEvery patient with tumor of the extremity
should be considered for limb salvage ifshould be considered for limb salvage if
the tumor can be removed with anthe tumor can be removed with an
adequate margin and the resulting limb isadequate margin and the resulting limb is
worth savingworth saving
 No justification for limiting the limb salvageNo justification for limiting the limb salvage
process based only on the prognosisprocess based only on the prognosis

46. BARRIERS TO LIMBBARRIERS TO LIMB
SALVAGESALVAGE
 Poorly placed biopsy incisionsPoorly placed biopsy incisions
 Major Neurovascular involvementMajor Neurovascular involvement
 Displaced pathologic fractureDisplaced pathologic fracture
 Fungating and infected tumorsFungating and infected tumors
 Recurrence of malignant tumorsRecurrence of malignant tumors
 Inability to afford chemotherapyInability to afford chemotherapy

47.  Vascular involvement is not an absoluteVascular involvement is not an absolute
contraindication for limb salvage surgerycontraindication for limb salvage surgery
as vascular homografts can be used foras vascular homografts can be used for
reconstruction (bypass surgery) **reconstruction (bypass surgery) **
 In selected cases limb salvage can beIn selected cases limb salvage can be
combined with metastatectomycombined with metastatectomy
**Faenza A et al, Transplant Proc 2005:37(6):2692-3**Faenza A et al, Transplant Proc 2005:37(6):2692-3

48.  BoneBone
 NervesNerves
 VesselsVessels
 Soft tissue envelopeSoft tissue envelope
If three of these key components areIf three of these key components are
involved, the limb salvage is probablyinvolved, the limb salvage is probably
not worth consideringnot worth considering
THREE STRIKE RULE

49. GOALGOAL
 Painless limbPainless limb
 Functional, tumor free limbFunctional, tumor free limb
 Good psychological outcomeGood psychological outcome

50. SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up – MultidisciplinaryWork up – Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction

51. STAGINGSTAGING
Histogenic type of tumor
Local extent
Possibility of metastasis
Radiological staging Surgical staging
 The most important step in formulating aThe most important step in formulating a
treatment plantreatment plan

52. RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
 Probable diagnosisProbable diagnosis
 Define the anatomic extent of the lesionDefine the anatomic extent of the lesion
 MetastasisMetastasis

53. RADIOGRAPHYRADIOGRAPHY
 Site and number of lesionsSite and number of lesions
 Location in boneLocation in bone
 Type of destructionType of destruction
 Soft tissue massSoft tissue mass
 Matrix of tumourMatrix of tumour

54. CT SCANCT SCAN
 Evaluation of cortical penetrationEvaluation of cortical penetration
 Osseous detailsOsseous details
 Detecting pulmonary metastasisDetecting pulmonary metastasis

55. MRIMRI
 Evaluation of the intra-medullary extent ofEvaluation of the intra-medullary extent of
the tumorthe tumor
 Soft tissue componentSoft tissue component
 Relationship to neurovascularRelationship to neurovascular
structuresstructures
 Skip lesionsSkip lesions
 Plan the surgical marginsPlan the surgical margins

56. ANGIOGRAPHYANGIOGRAPHY
 Difficult anatomic locationDifficult anatomic location
 Limb salvage surgery where someLimb salvage surgery where some
neurovascular bundle must be sacrificed andneurovascular bundle must be sacrificed and
reconstructedreconstructed
 Micro vascular surgeryMicro vascular surgery
 Intra-arterial chemotherapyIntra-arterial chemotherapy
 Pre operative EmbolisationPre operative Embolisation

57. SCINTIGRAPHYSCINTIGRAPHY
Tech 99m MDPTech 99m MDP
 Estimate the local intramedullary extentEstimate the local intramedullary extent
 Screen for other skeletal areas ofScreen for other skeletal areas of
involvementinvolvement
TL- 201 and DMSAVTL- 201 and DMSAV
 Differentiation of primary & metastaticDifferentiation of primary & metastatic
lesions, benign & malignant cartilage lesionslesions, benign & malignant cartilage lesions

58. PET SCANPET SCAN
 Effect ofEffect of
chemotherapychemotherapy
(Necrosis of tumor(Necrosis of tumor
mass)mass)
 Investigation ofInvestigation of
choice for metastaticchoice for metastatic
lesions with unknownlesions with unknown
primary lesionprimary lesion
 Residual tumorResidual tumor
 Recurrence of tumorRecurrence of tumor

59. SURGICAL STAGINGSURGICAL STAGING
 FNAC or Needle biopsyFNAC or Needle biopsy
 Core biopsyCore biopsy
 Incisional biopsyIncisional biopsy
 Excisional biopsyExcisional biopsy
 BIOPSYBIOPSY
Accurate diagnosisAccurate diagnosis
Histological gradeHistological grade

60. PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision

61. Work through muscle not anatomical plane
Drain in the line of incision
Oval window

62. RESTAGING AFTER PRE OPRESTAGING AFTER PRE OP
ADJUVANT THERAPYADJUVANT THERAPY
Indicators for favorable responseIndicators for favorable response
 ↓↓ tumor volumetumor volume
 ↓↓ in angiographic vascularityin angiographic vascularity
 Changes in plain X-ray/CT and/or MRI patternsChanges in plain X-ray/CT and/or MRI patterns
of matrix appearanceof matrix appearance
PET scans are better than MRI & CT for depictingPET scans are better than MRI & CT for depicting
residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment

63. PRINCIPLESPRINCIPLES
 Resection of tumorResection of tumor
 Skeletal reconstructionSkeletal reconstruction
 Soft tissue & muscle transferSoft tissue & muscle transfer

64. RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS
 IntralesionalIntralesional
 MarginalMarginal
 Wide resectionWide resection
 Radical resectionRadical resection
(As described by Enneking)

65.  Exactly what constitutes an adequateExactly what constitutes an adequate
margin in any particular case remainsmargin in any particular case remains
controversialcontroversial
 For high grade sarcomas, a wide margin isFor high grade sarcomas, a wide margin is
considered adequateconsidered adequate
 In low grade tumors or in high gradeIn low grade tumors or in high grade
tumors where preoperative radiationtumors where preoperative radiation
therapy has been given, a marginaltherapy has been given, a marginal
margin may be adequate.margin may be adequate.

66. Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants & curetting

67. SURGICAL ADJUVANTSSURGICAL ADJUVANTS
 Local physical or chemical agentsLocal physical or chemical agents
CryosurgeryCryosurgery
Methacrylate augmentationMethacrylate augmentation
Nitrogen mustard, Merthiolate, HypertonicNitrogen mustard, Merthiolate, Hypertonic
salinesaline
Carbolic acidCarbolic acid
High concentration ethanolHigh concentration ethanol
Bisphosphonates in Giant cell tumor of boneBisphosphonates in Giant cell tumor of bone

68.  Chemotherapy – Neoadjuvant or AdjuvantChemotherapy – Neoadjuvant or Adjuvant
 RadiotherapyRadiotherapy
 ImmunotherapyImmunotherapy
Specific – Active and PassiveSpecific – Active and Passive
Nonspecific – IFN and CSF’sNonspecific – IFN and CSF’s

69. RECONSTRUCTIONRECONSTRUCTION
 ArthrodesisArthrodesis
 Osteoarticular allograftOsteoarticular allograft
 Endoprosthetic replacementEndoprosthetic replacement
 Allograft Prosthetic compositeAllograft Prosthetic composite
 RotationplastyRotationplasty
 Autoclaved tumor boneAutoclaved tumor bone

70. ARTHRODESISARTHRODESIS
 With acute docking and shorteningWith acute docking and shortening
 With bone graftingWith bone grafting
 AllograftAllograft
 Autograft (fibula,iliac crest,ribs)Autograft (fibula,iliac crest,ribs)
 Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNAL
Long ILN
Plating
EXTERNAL
Ilizarov
External fixator
Charnleys clamp

72. ALLOGRAFTALLOGRAFT

73.  Advantages:Advantages:
 Length can be adjustedLength can be adjusted
 Biological soft tissueBiological soft tissue
healinghealing
 Avoid the risks andAvoid the risks and
complications ofcomplications of
intramedullary fixation ofintramedullary fixation of
endoprosthesis.endoprosthesis.
 Direct attachment ofDirect attachment of
remaining musculature.remaining musculature.
 Disadvantages:Disadvantages:
 Long healing timeLong healing time
 Potential for transfer ofPotential for transfer of
disease and infectiondisease and infection
 Immune rejectionImmune rejection
 Necessity of articular surfaceNecessity of articular surface
size matchingsize matching
 FractureFracture
 InfectionInfection
 Non-unionNon-union

74. AUTOGRAFTAUTOGRAFT

75. VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT
 Can heal in hostile environment (IrradiatedCan heal in hostile environment (Irradiated
tissue and active infection)tissue and active infection)
 Addresses the complications such as hostAddresses the complications such as host
allograft nonunion and allograft fracture**allograft nonunion and allograft fracture**
**The Journal of Bone and Joint Surgery (American). 2008;90:93-100.

76. ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS
 Large metallic device designed to replaceLarge metallic device designed to replace
the excised length of bone and thethe excised length of bone and the
adjacent jointadjacent joint
 Modified hinge designModified hinge design

77. Proximal femoral prosthesis Saddle prosthesis

78. Proximal humeral
prosthesis
Proximal tibial prosthesis Distal femoral
prosthesis

79. AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT

80. ALLOGRAFT PROSTHETICALLOGRAFT PROSTHETIC
COMPOSITECOMPOSITE
 Allograft provides aAllograft provides a
source of bone stocksource of bone stock
& site for tendon& site for tendon
insertions, while theinsertions, while the
prosthesis provides aprosthesis provides a
reliable & stablereliable & stable
articulation & somearticulation & some
support for allograftsupport for allograft

82. ROTATIONPLASTYROTATIONPLASTY
 Amputation of the legAmputation of the leg
above the knee, lowerabove the knee, lower
leg and foot are rotatedleg and foot are rotated
180 degrees, tibia is180 degrees, tibia is
then fused to thethen fused to the
proximal femur. Theproximal femur. The
ankle now functions inankle now functions in
place of the knee jointplace of the knee joint

83. LIMB SALVAGE IN UPPERLIMB SALVAGE IN UPPER
EXTREMITYEXTREMITY
 HANDHAND
 WRIST – Arthrodesis or ReconstructionWRIST – Arthrodesis or Reconstruction
 ELBOW – ReconstructionELBOW – Reconstruction
 HUMERUS – Arthrodesis orHUMERUS – Arthrodesis or
ReconstructionReconstruction
 SCAPULA - Scapulectomy orSCAPULA - Scapulectomy or
ReconstructionReconstruction

84. LIMB SALVAGE IN LOWERLIMB SALVAGE IN LOWER
EXTREMITYEXTREMITY
 ANKLE – Arthrodesis or ReconstructionANKLE – Arthrodesis or Reconstruction
 KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction
 FEMUR – Arthrodesis or ReconstructionFEMUR – Arthrodesis or Reconstruction
 PELVIS – Resection and Arthrodesis orPELVIS – Resection and Arthrodesis or
ReconstructionReconstruction

85. LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
 RotationplastyRotationplasty
 Tibial turn upTibial turn up
( Turno plasty)( Turno plasty)
 Modular ExpandableModular Expandable
prosthesis**prosthesis**
**Michael D Neel etal, Cancer control Aug 2001

86. CONCLUSIONCONCLUSION
 Limb salvage has become accepted standardLimb salvage has become accepted standard
care of the patients with malignant bone tumorscare of the patients with malignant bone tumors
 Success depends on prompt and early referralSuccess depends on prompt and early referral
by primary care doctor and on careful andby primary care doctor and on careful and
coordinated sequencing of events.coordinated sequencing of events.
 Achieving a surgical margin that will ensure aAchieving a surgical margin that will ensure a
low rate of local recurrence is paramount.low rate of local recurrence is paramount.
 Multidisciplinary approach is requiredMultidisciplinary approach is required