1. Limb Sparing surgery for bone tumors around the knee, KHMC experience Ghaith Abou-Nouar. MD,FACS Orth. Mohammad Al Alwan. MD Head of orthopedic oncology unit Orthopedic Tumor surgeon King Hussein Medical Centre Royal Medical Services of Jordan 1

2. Outlines and Objectives History of orthopedic Oncology at KHMC ( reflecting that our development was based on strong roots). Progress from the Past ( demonstrating how it followed international scientific guidelines). Demonstrating current concepts and updates. Retrospective analysis Limb sparing surgery for bone tumors around the knee: The king Hussein Medical Center (KHMC) experience. Prospects for the future (to alleviate suffering from cancer). Take home messages ( that could help in keeping us out of trouble). 2

3. History of Orthopedic Oncology at KHMC Orthopedic oncology at KHMC has its roots in European medicine of the 1800s. Sarcomas were first classified on the basis of their gross characteristics(1804). Amended on the basis of their histologic features ( 1867) 3

4. History of orthopedic oncology Surgical management, local excision, with unacceptable mortality gave way to amputation in the 1870. Limb-sparing resection was cautiously embarked upon in the mid 1900s 4

5. History of orthopedic oncology Nonsurgical adjuvant was first devised in the 1880s ( as Coly’s toxins) but remained largely ineffective until the advent of chemotherapy in the 1970s. The combination of chemotherapy with improved staging and reconstructive techniques has led to limb-salvage and greatly improved survival rates. 5

6. Establishment of orthopedic department Since the beginning of 1972 orthopedic surgery began as part of the department of general surgery at Amman military hospital. In 1974 was transferred to King Hussein Medical city. In 1980, orthopedic surgery became an independent department headed by Dr. Attalah, but remained receiving general surgeons to start their orthopedic fellowship program. In 1982 the department of orthopedic surgery moved to the Royal rehabilitation center. In 1995 Dr. Abou-Nouar established a five year independent orthopedics residency program ending by the Jordanian orthopedic board exam. 6

7. Progress from the Past to current concepts and practice, Tumor Local excision: High mortality Amputation: Decreased mortality Limb Salvage: If done when indicated decreases mortality otherwise amputation is better. 7

8. Progress from the past to current concepts and practice Modular 8

9. Progress from the past to current concepts and practice Intercalary 9

10. Progress from the past to current concepts and practice Growing 10

11. Progress from the past to current concepts and practice Extensor mechanism reconstruction using synthetic implants: Polyester (non absorbable) bands. Ex LARS ligament Augmentation of a Transposed muscle 11

12. Progress from the past to current concepts and practice Ex LARS ligament Complete soft tissue bridging and endoprosthesis coverage after resection 12

13. Progress from the past to current concepts and practice. Improvements in imaging techniques : 3D planning and simulation of operations and computer-assisted construction of endoprostheses in bone tumor. VIRTOPS: virtual operation planning in orthopedic surgery High morbidity of open biopsies, is there something else? Lets a wide door open for future research 13

14. Progress from the past to current concepts and practice. Van Nes Rotationplasty in Tumor Surgery 14

15. Retrospective analysis 15 Limb sparing surgery for bone tumors around the knee: The king Hussein Medical Center (KHMC) experience Abstract Background: Lower limb sparing surgeries for malignant and invasive benign bone tumors around the knee is of great clinical challenge for doctors and surgeons. Increasing bone tumors rate and occurrence around the knee continuously challenges surgeons to attempt developing and improving limb sparing surgical procedures enabling the patient to preserve the lower limb with a satisfactory functional outcome. Purpose: examining various limb sparing procedures. Methodology: a study was conducted (historical period covered January 2005 to December 2011) analyzing 30 patients with bone tumors around the knee treated with various limb salvage procedures. The tumors included 25 primary malignancies, two metastases and three giant cell tumors; the lower femur was involved in 24 patients, and the upper tibia in six patients. The reconstruction procedures included 28 prosthetic replacements, two autologous fibular grafts.

16. Retrospective analysis 16 Results: With 30 months as a follow-up, local recurrences occurred in two cases and systemic metastases in seven. Twelve patients died and 18 survived and remained disease free. The five year Kaplan-Meier survival rate of the 27 patients with malignancies was 40.4 % (those who passed 5 years of follow up in our study). The average Musculoskeletal Tumor Society (MSTS) functional score was 60 % (range 20– 100 %) in all patients. Conclusion: We concluded that bone tumors around the knee treated by the introduction of tumor endoprosthesis limb sparing surgery into our service improved the outcome and decreased the mortality and morbidity of our patients.

17. The Limb Salvage procedures A. Biological reconstruction: (Autogenous Fibular graft)

18. B. Modular Endoprothesis designed by Dr.Kotz : (Stryker and Hipokrat Modular Resection Systems ) (Custom Made Growing Endoprosthesis) (HMRS, GMRS)

19. The Indication for Endoprosthesis 1. Malignant bone tumors: A. Osteosarcoma 40% B. Ewing’s sarcoma 26% C. Chondrosarcoma 10% D. Others 15% 2. Invasive Benign bone tumor (Giant Cell tumor) 10%

20. Endoprosthetic Replacement Advantages 1.Early stability. 2.Early mobilization. 3.Early weight bearing. 4.Shorter operating time and hospital stay. 5. Early introduction of postoperative adjuvant chemotherapy. 6.Good functional results in most of the cases.

21. 3. Reconstruction of the extensor system, which done mainly through crossed sutures and reattachment of residual muscles and tendons around the knee.

22. 4.Satisfactory soft tissue coverage. (Usually we use gastrocenemius muscle for proximal tibia coverage )

23. Post operative care 1.Back slab or knee brace applied for restricted knee range of motion up to 6 weeks. 2.Functional exercises of foot, ankle and hip are started as soon as possible. 3.After soft tissue had healed and the knee joint stabilized, the passive and active motion are started. 4.Adjuvant chemotherapy when indicated starts 2 weeks post surgery. 5. We evaluate our patients according to the MSTS scoring system in regular follow-up.

24. MSTS

25. Case Demonstration 1 A 16 year old female patient. Left distal femur and Proximal tibia Ewing’s sarcoma. Stage IIB

27. Case demonstration 2 A 20 year old male patient. Right distal femur osteosarcoma. Stage IIB

29. Case demonstration 3 A 14 year old female patient. Right distal femur Ewing’s sarcoma. Stage IIB.

31. Case demonstration 4 A 17 year old female. Left distal femur Ewing’s sarcoma. Stage IIB

33. Case Demonstration 5 A 20 year old female pt. RT distal femur osteosarcoma. Stage IIB.

35. Survival rate: *The five year survival rate of our 25 patients with primary malignant bone tumors alone was 60%. *This rate is lower than the rates in Europe countries which usually is 70%-75% for primary malignant bone tumors.

36. Survival rate: We believe that the main reason for the differences in survival rates is that more than 50% of our patients presented to our service at an advanced stage. Undergoing tumor workup

37. Prospects for the future Providing state-of-the-art comprehensive cancer care to the people of Jordan and the Middle East region. Offering access to education, training and public awareness aimed at early detection and prevention of cancer. Supplying access to research in order to decrease mortality and alleviate suffering from cancer with the highest ethical standards and quality of care. 37

38. Take home messages Malignant bone tumors are of major concern in orthopedic surgery and treatment should be started as soon as possible. In our opinion, endoprosthesis should be considered as treatment of choice for bone tumors in the knee joint region to improve patients quality of life. Always keep in mind the clinical aspects. Communication with other experts and specialists. Be familiar with the updates. Don’t hesitate to take other opinions. Accept a less functional outcome on the account of decreased morbidity-mortality rate. 38