1. 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

2. 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 .

3. 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

4. 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.

5. 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

6. 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

7. 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.

8. 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.

9. 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.

10. 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

11. 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.

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

13. 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

14. Advantages of the modular segmental replacement
Simplicity
Adaptability
Reduced operating time

15. Some examples of megaprosthetic replacement for malignant bone tumors

16. Osteosarcoma Proximal Humerus

17. 14 yr old boy

18. 50 yr old man with liver mets

19. 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

20. 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.

21. Revision of megaprosthesis

22. 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.

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

24. 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.

25. Thank You & welcome to Delhi!