Tumor, limb salvage, hip and knee

1. RECONSTRUCTIVE SURGERIES OFRECONSTRUCTIVE SURGERIES OF
TUMORS AROUND HIP AND KNEE JOINTTUMORS AROUND HIP AND KNEE JOINT
(LIMB SALVAGE SURGERIES)(LIMB SALVAGE SURGERIES)
Dr. Sushil Paudel

2. 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

3. 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

4. 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}

5. Preoperative evaluationPreoperative 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

6. Biopsy

7. Principles of biopsyPrinciples 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.

8. Osteosarcoma

9. Plain X-ray
Affected bone and joint
Chest X-ray
Skeletal survey
MRI: Investigation of choice
Soft tissue extent
Skip lesion
Vascularity of tumor
Neurovascular involvement
Radiological investigations

10. 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..)

11. MRI DSA

12. Staging of tumorStaging of tumor
Enneking system :
Benign tumor : Latent
Active
Aggressive
Malignant tumor
Stage Grade Site Metastasis
IA G1 T1 M0
IB G1 T2 M0
IIA G2 T1 M0
IIB G2 T2 M0
III G1-2 T2 M1

13. 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.

14. Psychosocial andPsychosocial and
functional evaluationfunctional evaluation
Musculoskeletal tumor society functional
score.
• Pain, function, acceptance,gait.
Short form 36.
Toronto extremity salvage score.

15. Role of chemotherapy andRole of chemotherapy and
radiotherapyradiotherapy
 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

16. Regimen of chemotherapy of osteosarcoma:Regimen of chemotherapy of osteosarcoma:
AIIMS ProtocolAIIMS 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

17. 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

18. Surgical margin

19. 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

20. 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

21. Salvaged limbSalvaged limb
 Acceptable degree of function
 Cosmetic appearance
 Minimal amount of pain
 Durable enough to withstand the
demands of normal daily activities

22. 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 epiphysis
Pulmonary metastasis is not a contraindication
of surgery
Contraindications of limb salvage are the indications for
amputation

23. 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

24. Principles & TechniquesPrinciples & Techniques
Resection of tumor – Principles of surgical oncology
Skeletal reconstruction – Principles of orthopaedic
surgery
Soft tissue & muscle transfer – Principles of plastic
surgery

25. Resection of tumor :
Intra articular
Extra articular
Margin → 5-7 cm *
Adherent neurovascular bundles - amputation
Surgical margin - near neurovascular bundle
(* OCNA JAN 91)

26. KNEE

27. Methods of ReconstructionMethods of Reconstruction
 Arthrodesis
 Mobile joint reconstruction
− Osteoarticular allograft
− Endoprosthetic replacement
− Allograft Endoprosthetic composite
− Rotationplasty
− Autoclaved tumor bone

29. 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

30. 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

31. ARTHRODESIS OF HIP

32. 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
 PostoperativePostoperative

33. TURN O PLASTY

34. TURN O PLASTY

35. RECONSTRUCTION USING BONE GRAFT
Non-articular (Intercalary)
Articular reconstruction
Autograft
Allograft

36. Non-articular(Autogenous) graft
Advantage : 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)

37. 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

38. 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

39. 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.) :

40. 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

41. Osteoarticular graft (distal femur)
Large graft
Rigid 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

42. Reconstructions using autoclavedReconstructions using autoclaved
bone graftbone graft

43. 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

44. Proximal femoral endoprosthesis
Oldest, widely used method
Treatment of choiceTreatment of choice of patient with
limited life expectancy

45. Type of endoprosthesis
Bipolar
THR:
Short stem
 Long stem

47. Proximal femoral endoprosthesis
Advantage
No prolong protected weight bearing
Good ambulatory gait
No risk of transmission of disease / infection
Disadvantage
Mechanical failure
Loosening
Stress fracture

48. Proximal femoral endoprosthesis
14-18 mm diameter : Age, Size of patient and
Diameter of femur
Length 135-200mm
Anterior bow
Modular prosthesis : Extramedullary porous in
growth material on the segment proximal to stem.
Trial in reduction

49. Postoperative
Hip spica
Instability during surgery : Abduction brace : 2-3 months

50. 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

51. Segmental custom made total knee
replacement
Indications
Primary malignant tumor
Metastatic tumor
Stage three begin tumor

52. MODULAR CUSTOM MADE
KNEE JOINT

53. 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

54. 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

55. 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

56. 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

57. Alloprosthesis
 Endoprosthesis fixed to a allograft rigidly fixed with host
bone
HIP:
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

58. Younger patientsYounger patients
Rotation plasty : Act like a below knee
amputation
Expandable prosthesis
Arthrodesis of hip

59. 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

60. ROTATIONPLASTY
AII
BI
BII
BIII
AI

61. 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

62. Expandable prosthesis :
Hollow titanium tube assembled over a threaded shaft and
fitted with a adjustable ring.
Lengthening : -1 to 2 cm at a time

63. Soft tissue reconstruction
HIP-
Capsule
Abductor
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

64. Extensor mechanism KNEE JOINT
Patellar 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°

65. 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

66. 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

68. KEEP
CONFERENCE HALL
CLEAN
PLEASE DISPOSE
EMPTY BOXES
OUTSIDE THE HALL