Limb salvage (saving) surgery for malignant bone tumors of limbs Dr (Prof) Raju Vaishya (MBBS, MS, MCh, FRCS) Senior Consultant Dept of Orthopaedics & Joint Replacement Surgery Indraprastha Apollo Hospitals, New Delhi, INDIA

Malignant bone tumors: now & then Amputation had been the standard method of treatment for most bone sarcomas, but the 1980s witnessed the development of limb-sparing surgery for most malignant bone tumors. Today, limb-saving surgery is considered safe and routine for approximately 90 % of patients with extremity malignant bone tumors .

Definition 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

Indication 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.

Contraindications Neurovascular involvement Large size tumour Displaced pathologic fracture(relative contraindication) Fungating and infected tumors Recurrence of malignant tumors Skeletal immaturity Pulmonary metastasis is not a contraindication of surgery Contraindications of limb salvage are the indications for amputation

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

Limb salvage surgery: Treatment options Currently, the 3 most popular options : 1. Endoprosthesis 2. Allograft prosthetic composite 3. Biological reconstructions Each of those methods has its short- and long-term advantages and disadvantages, & a surgeon should consider each patient individually.

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

RESECTION & 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.

Limb-salvage procedures: (Arthrodesis) Bone allografts, Vascularised autografts or both. Provides a stable, durable reconstruction which requires limited postoperative follow-up Inherent disadvantages: - Loss of joint function - Increased energy expenditure - Additional abnormal mechanical stress to other joints

Osteoarticular 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.

Allograft arthrodesis Most stable reconstruction for young pts with vigorous activities.

Limb-salvage procedures: (Arthroplasty) An arthroplasty preserves the joint. Allograft or a metallic prosthesis. Early metal designs were custom made, resulting in obvious manufacturing delays between diagnosis and reconstruction Present endoprosthetic reconstruction with the use of modular prosthesis

Advantages of the modular segmental replacement Simplicity Adaptability Reduced operating time

Some examples of megaprosthetic replacement for malignant bone tumors

Osteosarcoma Proximal Humerus

14 yr old boy

50 yr old man with liver mets

Megaprosthetic replacement: (Advantages) Modularity allows intraoperative flexibility Early ROM and weight bearing Lower risk of deep infection than do allografts, and non union is not a concern Avoids the risk of disease transmission & immune responses

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

Revision of megaprosthesis

Endoprosthetic Reconstruction 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 # at base of stem – difficult to remove.

Limb salvage Greater perioperative and long term morbidity More extensive surgical procedure Greater risk of infection & wound dehiscence Flap necrosis Blood loss DVT

Conclusions The surgical management of patients with malignant tumors of bone is challenging. The modular segmental replacement in limb sparing surgery for bone tumors results in satisfactory results in terms of tumor control and limb function. Amputation remains as a valid procedure in cases where limb preservation is not possible.

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