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HYPERPLASIA METAPLASIA ANAPLASIAHYPERPLASIA METAPLASIA ANAPLASIA
NEOPLASIA TNM CLASSIFICATION AND ITSNEOPLASIA TNM CLASSIFICATION AND ITS
ORTHOPAEDIC APPLICATIONS SURGICALORTHOPAEDIC APPLICATIONS SURGICAL
CLASSIFICATION HISTOLOGIC CLASSIFICATION HISTOLOGIC
CLASSIFICATION AND PRINCIPLES OF LIMB CLASSIFICATION AND PRINCIPLES OF LIMB
SALVAGE SURGERYSALVAGE SURGERY
Dr Sushil PaudelDr Sushil Paudel
NEOPLASIANEOPLASIA
A neoplasm is an A neoplasm is an abnormal mass of abnormal mass of tissue growth of tissue growth of which exceeds amp is which exceeds amp is uncoordinated with uncoordinated with that of the normal that of the normal tissues tissues
Willis RA The spread of tumours in the human body London Butterworth amp Co 1952
HYPERPLASIAHYPERPLASIA
Increase in the number of cells in an Increase in the number of cells in an organ or tissueorgan or tissue
Physiological hyperplasiaPhysiological hyperplasia
Pathological hyperplasiaPathological hyperplasia
METAPLASIAMETAPLASIA
Reversible change in which one cell Reversible change in which one cell type (epithelial or mesenchymal) is type (epithelial or mesenchymal) is replaced by another replaced by another
Epithelial metaplasiaEpithelial metaplasia
Connective tissue metaplasiaConnective tissue metaplasia
Eg Myositis ossificansEg Myositis ossificans
DIFFERENTIATION AND DIFFERENTIATION AND ANAPLASIAANAPLASIA
Anaplasia is loss of Differentiation Anaplasia is loss of Differentiation
PleomorphismPleomorphism
Altered NC ratioAltered NC ratio
Atypical mitosesAtypical mitoses
Tumor giant cellsTumor giant cells
DYSPLASIA DYSPLASIA
Disordered growthDisordered growth Loss in the uniformity of individual Loss in the uniformity of individual
cells as well as loss in architectural cells as well as loss in architectural orientation orientation
CLASSIFICATION OF BONE TUMORS
HISTORYHISTORY
Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman
Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry
Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993
Schajowicz etalCancer 1995 Mar
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM 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 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign 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-High Stage IIB-High
gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO 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 tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
NEOPLASIANEOPLASIA
A neoplasm is an A neoplasm is an abnormal mass of abnormal mass of tissue growth of tissue growth of which exceeds amp is which exceeds amp is uncoordinated with uncoordinated with that of the normal that of the normal tissues tissues
Willis RA The spread of tumours in the human body London Butterworth amp Co 1952
HYPERPLASIAHYPERPLASIA
Increase in the number of cells in an Increase in the number of cells in an organ or tissueorgan or tissue
Physiological hyperplasiaPhysiological hyperplasia
Pathological hyperplasiaPathological hyperplasia
METAPLASIAMETAPLASIA
Reversible change in which one cell Reversible change in which one cell type (epithelial or mesenchymal) is type (epithelial or mesenchymal) is replaced by another replaced by another
Epithelial metaplasiaEpithelial metaplasia
Connective tissue metaplasiaConnective tissue metaplasia
Eg Myositis ossificansEg Myositis ossificans
DIFFERENTIATION AND DIFFERENTIATION AND ANAPLASIAANAPLASIA
Anaplasia is loss of Differentiation Anaplasia is loss of Differentiation
PleomorphismPleomorphism
Altered NC ratioAltered NC ratio
Atypical mitosesAtypical mitoses
Tumor giant cellsTumor giant cells
DYSPLASIA DYSPLASIA
Disordered growthDisordered growth Loss in the uniformity of individual Loss in the uniformity of individual
cells as well as loss in architectural cells as well as loss in architectural orientation orientation
CLASSIFICATION OF BONE TUMORS
HISTORYHISTORY
Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman
Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry
Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993
Schajowicz etalCancer 1995 Mar
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM 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 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign 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-High Stage IIB-High
gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO 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 tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
HYPERPLASIAHYPERPLASIA
Increase in the number of cells in an Increase in the number of cells in an organ or tissueorgan or tissue
Physiological hyperplasiaPhysiological hyperplasia
Pathological hyperplasiaPathological hyperplasia
METAPLASIAMETAPLASIA
Reversible change in which one cell Reversible change in which one cell type (epithelial or mesenchymal) is type (epithelial or mesenchymal) is replaced by another replaced by another
Epithelial metaplasiaEpithelial metaplasia
Connective tissue metaplasiaConnective tissue metaplasia
Eg Myositis ossificansEg Myositis ossificans
DIFFERENTIATION AND DIFFERENTIATION AND ANAPLASIAANAPLASIA
Anaplasia is loss of Differentiation Anaplasia is loss of Differentiation
PleomorphismPleomorphism
Altered NC ratioAltered NC ratio
Atypical mitosesAtypical mitoses
Tumor giant cellsTumor giant cells
DYSPLASIA DYSPLASIA
Disordered growthDisordered growth Loss in the uniformity of individual Loss in the uniformity of individual
cells as well as loss in architectural cells as well as loss in architectural orientation orientation
CLASSIFICATION OF BONE TUMORS
HISTORYHISTORY
Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman
Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry
Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993
Schajowicz etalCancer 1995 Mar
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM 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 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign 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-High Stage IIB-High
gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO 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 tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
METAPLASIAMETAPLASIA
Reversible change in which one cell Reversible change in which one cell type (epithelial or mesenchymal) is type (epithelial or mesenchymal) is replaced by another replaced by another
Epithelial metaplasiaEpithelial metaplasia
Connective tissue metaplasiaConnective tissue metaplasia
Eg Myositis ossificansEg Myositis ossificans
DIFFERENTIATION AND DIFFERENTIATION AND ANAPLASIAANAPLASIA
Anaplasia is loss of Differentiation Anaplasia is loss of Differentiation
PleomorphismPleomorphism
Altered NC ratioAltered NC ratio
Atypical mitosesAtypical mitoses
Tumor giant cellsTumor giant cells
DYSPLASIA DYSPLASIA
Disordered growthDisordered growth Loss in the uniformity of individual Loss in the uniformity of individual
cells as well as loss in architectural cells as well as loss in architectural orientation orientation
CLASSIFICATION OF BONE TUMORS
HISTORYHISTORY
Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman
Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry
Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993
Schajowicz etalCancer 1995 Mar
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM 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 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign 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-High Stage IIB-High
gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO 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 tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
DIFFERENTIATION AND DIFFERENTIATION AND ANAPLASIAANAPLASIA
Anaplasia is loss of Differentiation Anaplasia is loss of Differentiation
PleomorphismPleomorphism
Altered NC ratioAltered NC ratio
Atypical mitosesAtypical mitoses
Tumor giant cellsTumor giant cells
DYSPLASIA DYSPLASIA
Disordered growthDisordered growth Loss in the uniformity of individual Loss in the uniformity of individual
cells as well as loss in architectural cells as well as loss in architectural orientation orientation
CLASSIFICATION OF BONE TUMORS
HISTORYHISTORY
Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman
Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry
Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993
Schajowicz etalCancer 1995 Mar
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM 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 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign 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-High Stage IIB-High
gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO 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 tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
DYSPLASIA DYSPLASIA
Disordered growthDisordered growth Loss in the uniformity of individual Loss in the uniformity of individual
cells as well as loss in architectural cells as well as loss in architectural orientation orientation
CLASSIFICATION OF BONE TUMORS
HISTORYHISTORY
Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman
Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry
Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993
Schajowicz etalCancer 1995 Mar
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM 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 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign 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-High Stage IIB-High
gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO 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 tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
CLASSIFICATION OF BONE TUMORS
HISTORYHISTORY
Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman
Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry
Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993
Schajowicz etalCancer 1995 Mar
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM 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 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign 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-High Stage IIB-High
gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO 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 tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
HISTORYHISTORY
Dates back to 1920 origin of Bone Dates back to 1920 origin of Bone Sarcoma Registry by Dr CodmanSarcoma Registry by Dr Codman
Dr Codman along with James Ewing and Dr Codman along with James Ewing and Bloodgod drew up in 1922 the first Bloodgod drew up in 1922 the first classification of the Registryclassification of the Registry
Efforts of many pathologists and Efforts of many pathologists and oncologists has given shape to Revised oncologists has given shape to Revised WHO Histologic Classification of Bone WHO Histologic Classification of Bone tumours in 1993 tumours in 1993
Schajowicz etalCancer 1995 Mar
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM 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 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign 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-High Stage IIB-High
gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO 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 tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
Primary tumour (T) TX primary tumour cannot be assessedT0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone siteRegional lymph nodes (N) NX regional lymph nodes cannot be assessedN0 no regional lymph node metastasisN1 regional lymph node metastasisNote Regional node involvement is rare and cases in which nodal status is not assessed eitherclinically or pathologically could be considered N0 instead of NX or pNXDistant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
TNM CLASSIFICATIONTNM CLASSIFICATION
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM 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 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign 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-High Stage IIB-High
gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO 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 tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
Translation table for lsquothreersquo and lsquofour gradersquo to lsquotwo gradersquo (low vs high grade) systemTNM 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 4Note Ewing sarcoma is classified as high gradeStage IA T1 N0NX M0 Low gradeStage IB T2 N0NX M0 Low gradeStage IIA T1 N0NX M0 High gradeStage IIB T2 N0NX M0 High gradeStage III T3 N0NX M0 Any gradeStage IVA Any T N0NX M1a Any gradeStage IVB Any T N1 Any M Any gradeAny T Any N M1b Any grade
HISTOPATHOLOGICAL HISTOPATHOLOGICAL GRADINGGRADING
Benign Benign 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-High Stage IIB-High
gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO 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 tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
Benign Benign 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-High Stage IIB-High
gradeextracompartmentalgradeextracompartmental
Stage III - MetastaticStage III - Metastatic
ENNEKING STAGINGENNEKING STAGING
WHO HISTOLOGICAL WHO 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 tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
WHO HISTOLOGICAL WHO 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 tumours Lipogenic tumours Neural tumoursNeural tumours Miscellaneous tumoursMiscellaneous tumours Joint lesions Joint lesions Each class is further divided into benign and malignantEach class is further divided into benign and malignant
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
BONE FORMING (Osteogenic) BONE FORMING (Osteogenic) LESIONS LESIONS
BENIGN LESIONS BENIGN LESIONS OsteomaOsteoma Enostoses (Bone island)Enostoses (Bone island) Osteoid osteomaOsteoid osteoma OsteoblastomaOsteoblastoma
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
MALIGNANT LESIONSMALIGNANT LESIONS
OSTEOSARCOMASOSTEOSARCOMAS share the ability to form osteoid from the share the ability to form osteoid from the
neoplastic cellsneoplastic cells
MODIFIED WHO CLASSIFICATIONMODIFIED WHO CLASSIFICATION
Takes into account etiology localisationTakes into account etiology localisation
bone specific topography and histologybone specific topography and histology
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
PRIMARY OSTEOSARCOMASPRIMARY OSTEOSARCOMAS
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
INTRACORTICAL OSTEOSARCOMAINTRACORTICAL OSTEOSARCOMA
SURFACE OSTEOSARCOMASURFACE OSTEOSARCOMA
EXTRASKELETAL OSTEOSARCOMAEXTRASKELETAL OSTEOSARCOMA
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
INTRAOSSEOUS OSTEOSARCOMAINTRAOSSEOUS OSTEOSARCOMA
1 INTRAMEDULLARY1 INTRAMEDULLARY
OsteoblasticOsteoblastic
ChondroblasticChondroblastic
FibrogenicFibrogenic
EpithelioidEpithelioid
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
IMAGINGIMAGING
Medullary and cortical bone destruction aggressive periosteal reaction of the velvet and sunburst types soft tissue mass contains tumor bone
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
HISTOPATHOLOGYHISTOPATHOLOGY
Markedly pleomorphic tumor cells are separated by lace-like osteoid
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
2MALIGNANT FIBROUS HISTIOCYTOMA 2MALIGNANT FIBROUS HISTIOCYTOMA LIKE (Fibrohistiocytic) OSTEOSARCOMALIKE (Fibrohistiocytic) OSTEOSARCOMA
3GIANT CELL RICH OSTEOSARCOMA3GIANT CELL RICH OSTEOSARCOMA
4SMALL CELL OSTEOSARCOMA4SMALL CELL OSTEOSARCOMA
5LOW GRADE CENTRAL OSTEOSARCOMA5LOW GRADE CENTRAL OSTEOSARCOMA
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
6TELANGIECTATIC OSTEOSARCOMA6TELANGIECTATIC OSTEOSARCOMA
Malignant bone aneurysmMalignant bone aneurysm
Aggressive and Aggressive and
poor prognosispoor prognosis
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
7GNATHIC OSTEOSARCOMA7GNATHIC OSTEOSARCOMA
8MULTIFOCAL OSTEOSARCOMA8MULTIFOCAL OSTEOSARCOMA
9 OSTEOSARCOMAS WITH UNUSUAL 9 OSTEOSARCOMAS WITH UNUSUAL CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
Werner syndrome Li fraumeni Werner syndrome Li fraumeni syndromesyndrome
Blooms syndrome RetinoblastomaBlooms syndrome Retinoblastoma syndromesyndrome
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
SECONDARY OSTEOSARCOMAS
PAGET SARCOMA
FIBROUS DYSPLASIA
BONE INFARCT
POST IRRADIATION
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
CARTILAGENOUS LESIONSCARTILAGENOUS LESIONS
BENIGN LESIONSBENIGN LESIONS CHONDROMACHONDROMA EnchondromaEnchondroma Periosteal chondromaPeriosteal chondroma Enchondromatosis ndash Enchondromatosis ndash Olliers disease Mafucci syndromeOlliers disease Mafucci syndrome Soft tissue chondromaSoft tissue chondroma
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
OSTEOCHONDROMAOSTEOCHONDROMA
Multiple hereditary Multiple hereditary
osteochondromataosteochondromata
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
CHONDROBLASTOMACHONDROBLASTOMA
( Codman tumor )( Codman tumor )
Preferred sitendash epiphysisPreferred sitendash epiphysis
CHONDROMYXOID FIBROMACHONDROMYXOID FIBROMA
SYNOVIAL SYNOVIAL OSTEOCHONDROMATOSISOSTEOCHONDROMATOSIS
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
MALIGNANT TUMOURSMALIGNANT TUMOURS CHONDROSARCOMACHONDROSARCOMA
PRIMARY CHONDROSARCOMASPRIMARY CHONDROSARCOMAS
CONVENTIONAL MEDULLARYCONVENTIONAL MEDULLARY
CHONDROSARCOMACHONDROSARCOMA
Destructive lesion in the medulla with annular and comma shaped calcifications andperiosteal new bone formation
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
CLEAR CELL CHONDROSARCOMACLEAR CELL CHONDROSARCOMA
MESENCHYMAL CHONDROSARCOMA MESENCHYMAL CHONDROSARCOMA
MYXOID CHONDROSARCOMAMYXOID CHONDROSARCOMA
DEDIFFERENTIATED CHONDROSARCOMA DEDIFFERENTIATED CHONDROSARCOMA
PERIOSTEAL CHONDROSARCOMAPERIOSTEAL CHONDROSARCOMA
SYNOVIAL CHONDROSARCOMASYNOVIAL CHONDROSARCOMA
EXTRASKELETAL CHONDROSARCOMAEXTRASKELETAL CHONDROSARCOMA
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
SECONDARY CHONDROSARCOMAS
ENCHONDROMA
OSTEOCHONDROMA
PAGETIC BONE
SYNOVIAL CHONDROMATOSIS
RADIATION INDUCED
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
FIBROGENIC FIBROOSSEOUS AND FIBROGENIC FIBROOSSEOUS AND FIBROHISTIOCYTIC LESIONSFIBROHISTIOCYTIC LESIONS
BENIGN LESIONS
FIBROUS CORTICAL DEFECTAND NON OSSIFYING FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
PERIOSTEAL DERMOID
FIBROUS DYSPLASIA
MONOSTOTICPOLYOSTOTIC
MC CUNE ALBRIGHT SYNDROMEMAZABRAUD SYNDROME
OSTEOFIBROUS DYSPLASIA(KEMPSON CAMPANACCI LESION)
Decided preference for Tibia
DESMOPLASTIC FIBROMA
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
FIBROSARCOMA AND MALIGNANT FIBROUS HISTIOCYTOMA
PRIMARY SECONDARY
Pagets diseaseFibrous dysplasia
Bone infarctChronic sinuses of osteomyelitis
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
ROUND CELL LESIONSROUND CELL LESIONS
BENIGN LESIONS
LANGERHANS CELL HISTIOCYTOSIS
Eusinophilic granulomaHand Schullers Christian disease
Letterer Siwe disease
Vertebra plana
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
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
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
MYELOMA MYELOMA (Plasmacytoma)(Plasmacytoma)
Most common Most common primary primary malignant malignant tumourtumour
TYPES
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
VASCULAR LESIONS VASCULAR LESIONS
BENIGN LESIONS
INTRAOSSEOUS HEMANGIOMA
SYNOVIAL HEMANGIOMA
CYSTIC ANGIOMATOSIS
GLOMUS TUMOUR
LYMPHANGIOMA
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
MALIGNANT LESIONS
EPITHELOID HEMANGIOENDOTHELIOMA
ANGIOSARCOMA
HEMANGIOPERICYTOMA
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
UNCLASSIFIED LESIONSUNCLASSIFIED LESIONS
GIANT CELL TUMOURGIANT CELL TUMOURBENIGN BENIGN
20-40 yr FgtM20-40 yr FgtM
Epiphyseal region Epiphyseal region of of
long boneslong bones
MALIGNANTMALIGNANT
Radiolucent eccentric expansive absence of reactive sclerosis
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
MISCELLANEOUS TUMORS AND MISCELLANEOUS TUMORS AND TUMOR LIKE LESIONSTUMOR LIKE LESIONS
BENIGNBENIGN SIMPLE BONE CYSTSIMPLE BONE CYST
Metaphyseal central lack of periosteal reaction
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
ANEURYSMAL BONE ANEURYSMAL BONE CYST CYST
lt20 yr FgtMlt20 yr FgtM Metaphysis of long Metaphysis of long
bonesbones
SOLID VARIANT OF SOLID VARIANT OF ANEURSYMAL BONE ANEURSYMAL BONE
CYSTCYST Giant cell reparativeGiant cell reparative granulomagranuloma
Radiolucent eccentric expansive butress of periosteal reaction
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
MALIGNANT LESIONSMALIGNANT LESIONS
ADAMANTINOMAADAMANTINOMA
CHORDOMACHORDOMA
LEIOMYOSARCOMA OF BONELEIOMYOSARCOMA OF BONE
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
rrOSSEOUS METASTASES
SOLITARY MULTIPLE CORTICAL
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
PRINCIPLES OF LIMB SALVAGE PRINCIPLES OF LIMB SALVAGE SURGERYSURGERY
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
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
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
HISTORY AND CHANGING HISTORY AND CHANGING TRENDTREND
Eiselberg in 1897Eiselberg in 1897 Lexer Lexer 1 1stst successful series of 6 patients successful series of 6 patients
Lexer Lexer concept of using allografts in tumor surgery concept of using allografts in tumor surgery (1907)(1907)
Major changes since 1970 with the advent of Major changes since 1970 with the advent of advanced imaging chemotherapy and radiotherapy advanced imaging chemotherapy and radiotherapy improved surgical techniquesimproved surgical techniques
Limb salvage possible in up to 85 cases Limb salvage possible in up to 85 cases Bacci G Picci 2 Pignatti GetalBacci G Picci 2 Pignatti Getal
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
INDICATIONINDICATION Every patient with tumor of the extremity Every patient with tumor of the extremity
should be considered for limb salvage if should be considered for limb salvage if
the tumor can be removed with an the tumor can be removed with an
adequate margin and the resulting limb is adequate margin and the resulting limb is
worth savingworth saving No justification for limiting the limb No justification for limiting the limb
salvage process based only on the salvage process based only on the
prognosisprognosis
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
BARRIERS TO LIMB BARRIERS 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
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
Vascular involvement is not an Vascular involvement is not an absolute contraindication for limb absolute contraindication for limb salvage surgery as vascular salvage surgery as vascular homografts can be used for homografts can be used for reconstruction (bypass surgery) reconstruction (bypass surgery)
In selected cases limb salvage can In selected cases limb salvage can be combined with metastatectomy be combined with metastatectomy
Faenza A et al Transplant Proc 200537(6)2692-3Faenza A et al Transplant Proc 200537(6)2692-3
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
BoneBone NervesNerves VesselsVessels Soft tissue envelopeSoft tissue envelope
If three of these key components If three of these key components are involved the limb salvage is are involved the limb salvage is probably not worth consideringprobably not worth considering
THREE STRIKE RULE
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
GOALGOAL
Painless limb Painless limb
Functional tumor free limbFunctional tumor free limb
Good psychological outcomeGood psychological outcome
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
SUCCESSSUCCESS
Early Management and ReferralEarly Management and Referral
Work up ndash MultidisciplinaryWork up ndash Multidisciplinary
StagingStaging
Patient EducationPatient Education
Surgical resection and ReconstructionSurgical resection and Reconstruction
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
STAGINGSTAGING
Histogenic type of tumor Local extent
Possibility of metastasis
Radiological staging Surgical staging
The most important step in The most important step in formulating a treatment planformulating a treatment plan
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
RADIOLOGICAL STAGINGRADIOLOGICAL STAGING
Probable diagnosisProbable diagnosis
Define the anatomic extent of the Define the anatomic extent of the lesionlesion
MetastasisMetastasis
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
RADIOGRAPHYRADIOGRAPHY
Site and number of lesionsSite and number of lesions Location in boneLocation in bone Type of destruction Type of destruction Soft tissue massSoft tissue mass Matrix of tumourMatrix of tumour
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
CT SCANCT SCAN
Evaluation of cortical Evaluation of cortical
penetrationpenetration
Osseous detailsOsseous details
Detecting pulmonary Detecting pulmonary
metastasismetastasis
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
MRIMRI Evaluation of the intra-medullary Evaluation of the intra-medullary
extent of extent of
the tumorthe tumor
Soft tissue component Soft tissue component
Relationship to neurovascularRelationship to neurovascular
structuresstructures
Skip lesionsSkip lesions
Plan the surgical marginsPlan the surgical margins
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
ANGIOGRAPHYANGIOGRAPHY Difficult anatomic locationDifficult anatomic location Limb salvage surgery where some Limb salvage surgery where some
neurovascular bundle must be sacrificed neurovascular bundle must be sacrificed and and
reconstructedreconstructed Micro vascular surgery Micro vascular surgery Intra-arterial chemotherapyIntra-arterial chemotherapy Pre operative EmbolisationPre operative Embolisation
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
SCINTIGRAPHYSCINTIGRAPHYTech 99m MDPTech 99m MDP
Estimate the local intramedullary extent Estimate the local intramedullary extent
Screen for other skeletal areas of Screen for other skeletal areas of
involvement involvement
TL- 201 and DMSAVTL- 201 and DMSAV
Differentiation of primary amp metastatic Differentiation of primary amp metastatic
lesions benign amp malignant cartilage lesions benign amp malignant cartilage
lesionslesions
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
PET SCANPET SCAN Effect of chemotherapy Effect of chemotherapy
(Necrosis of tumor (Necrosis of tumor mass)mass)
Investigation of choice Investigation of choice for metastatic lesions for metastatic lesions with unknown primary with unknown primary lesionlesion
Residual tumor Residual tumor
Recurrence of tumor Recurrence of tumor
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
SURGICAL STAGINGSURGICAL STAGING
FNAC or Needle biopsyFNAC or Needle biopsy
Core biopsyCore biopsy
Incisional biopsyIncisional biopsy
Excisional biopsyExcisional biopsy
BIOPSYBIOPSYAccurate diagnosisAccurate diagnosis
Histological gradeHistological grade
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
PRINCIPLES OF BIOPSYPRINCIPLES OF BIOPSY
Total excision of the tract Longitudinal incision
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
Work through muscle not anatomical plane
Drain in the line of incision Oval window
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
RESTAGING AFTER PRE OP RESTAGING 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-rayCT andor MRI patterns Changes in plain X-rayCT andor MRI patterns of matrix appearanceof matrix appearance
PET scans are better than MRI amp CT for depicting PET scans are better than MRI amp CT for depicting residual or recurrent tumor after treatmentresidual or recurrent tumor after treatment
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
PRINCIPLESPRINCIPLES
Resection of tumorResection of tumor
Skeletal reconstructionSkeletal reconstruction
Soft tissue amp muscle transferSoft tissue amp muscle transfer
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
RESECTIONRESECTION
SURGICAL MARGINSSURGICAL MARGINS IntralesionalIntralesional
MarginalMarginal
Wide resectionWide resection
Radical resectionRadical resection
(As described by Enneking)
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
Exactly what constitutes an adequate Exactly what constitutes an adequate margin in any particular case margin in any particular case remains controversialremains controversial
For high grade sarcomas a wide For high grade sarcomas a wide margin is considered adequate margin is considered adequate
In low grade tumors or in high grade In low grade tumors or in high grade tumors where preoperative radiation tumors where preoperative radiation therapy has been given a marginal therapy has been given a marginal margin may be adequate margin may be adequate
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
Tumor resection Margin Curetting of the tumor site
Burring of the resected tumor site Lavaging with Adjuvants amp curetting
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
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 bone Bisphosphonates in Giant cell tumor of bone
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
Chemotherapy ndash Neoadjuvant or Chemotherapy ndash Neoadjuvant or AdjuvantAdjuvant
RadiotherapyRadiotherapy Immunotherapy Immunotherapy
Specific ndash Active and PassiveSpecific ndash Active and Passive
Nonspecific ndash IFN and CSFrsquosNonspecific ndash IFN and CSFrsquos
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
RECONSTRUCTIONRECONSTRUCTION
ArthrodesisArthrodesis Osteoarticular allograftOsteoarticular allograft Endoprosthetic replacementEndoprosthetic replacement Allograft Prosthetic compositeAllograft Prosthetic composite RotationplastyRotationplasty Autoclaved tumor bone Autoclaved tumor bone
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
ARTHRODESISARTHRODESIS With acute docking and shorteningWith acute docking and shortening With bone graftingWith bone grafting
AllograftAllograft Autograft (fibulailiac crestribs)Autograft (fibulailiac crestribs) Autoclaved bone tumour graftAutoclaved bone tumour graft
FIXATION
INTERNALLong ILNPlating
EXTERNALIlizarov
External fixatorCharnleys clamp
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
ALLOGRAFTALLOGRAFT
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
Advantages Advantages
Length can be adjustedLength can be adjusted
Biological soft tissue Biological soft tissue
healinghealing
Avoid the risks and Avoid the risks and
complications of complications of
intramedullary fixation intramedullary fixation
of endoprosthesis of endoprosthesis
Direct attachment of Direct attachment of
remaining musculatureremaining musculature
Disadvantages Disadvantages Long healing timeLong healing time
Potential for transfer of Potential for transfer of
disease and infectiondisease and infection
Immune rejectionImmune rejection
Necessity of articular Necessity of articular
surface size matching surface size matching
FractureFracture
Infection Infection
Non-union Non-union
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
AUTOGRAFTAUTOGRAFT
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
VASCULARISED FIBULAR GRAFTVASCULARISED FIBULAR GRAFT Can heal in hostile environment Can heal in hostile environment
(Irradiated tissue and active infection)(Irradiated tissue and active infection)
Addresses the complications such as Addresses the complications such as host allograft nonunion and allograft host allograft nonunion and allograft fracture fracture
The Journal of Bone and Joint Surgery (American) 20089093-100
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
ENDOPROSTHESISENDOPROSTHESIS
MEGAPROSTHESISMEGAPROSTHESIS Large metallic device designed to Large metallic device designed to
replace the excised length of bone replace the excised length of bone and the adjacent jointand the adjacent joint
Modified hinge designModified hinge design
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
Proximal femoral prosthesis Saddle prosthesis
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
Proximal humeral prosthesis
Proximal tibial prosthesis Distal femoralprosthesis
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
AUTOCLAVED AUTOGRAFTAUTOCLAVED AUTOGRAFT
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
ALLOGRAFT PROSTHETIC ALLOGRAFT PROSTHETIC COMPOSITECOMPOSITE
Allograft provides a Allograft provides a source of bone source of bone stock amp site for stock amp site for tendon insertions tendon insertions while the prosthesis while the prosthesis provides a reliable provides a reliable amp stable articulation amp stable articulation amp some support for amp some support for allograftallograft
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
ROTATIONPLASTYROTATIONPLASTY
Amputation of the Amputation of the leg above the knee leg above the knee lower leg and foot lower leg and foot are rotated 180 are rotated 180 degrees tibia is degrees tibia is then fused to the then fused to the proximal femur proximal femur The ankle now The ankle now functions in place of functions in place of the knee jointthe knee joint
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
LIMB SALVAGE IN UPPER LIMB SALVAGE IN UPPER EXTREMITYEXTREMITY
HANDHAND WRIST ndash Arthrodesis or ReconstructionWRIST ndash Arthrodesis or Reconstruction ELBOW ndash ReconstructionELBOW ndash Reconstruction HUMERUS ndash Arthrodesis or HUMERUS ndash Arthrodesis or
ReconstructionReconstruction SCAPULA - Scapulectomy or SCAPULA - Scapulectomy or
ReconstructionReconstruction
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
LIMB SALVAGE IN LOWER LIMB SALVAGE IN LOWER EXTREMITYEXTREMITY
ANKLE ndash Arthrodesis or ReconstructionANKLE ndash Arthrodesis or Reconstruction KNEE - Arthrodesis or ReconstructionKNEE - Arthrodesis or Reconstruction FEMUR ndash Arthrodesis or ReconstructionFEMUR ndash Arthrodesis or Reconstruction PELVIS ndash Resection and Arthrodesis or PELVIS ndash Resection and Arthrodesis or
ReconstructionReconstruction
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
LIMB SALVAGE IN CHIDRENLIMB SALVAGE IN CHIDREN
RotationplastyRotationplasty Tibial turn upTibial turn up
( Turno plasty)( Turno plasty) Modular Expandable Modular Expandable
prosthesisprosthesis
Michael D Neel etal Cancer control Aug 2001
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required
CONCLUSIONCONCLUSION Limb salvage has become accepted standard care Limb salvage has become accepted standard care
of the patients with malignant bone tumorsof the patients with malignant bone tumors
Success depends on prompt and early referral by Success depends on prompt and early referral by
primary care doctor and on careful and coordinated primary care doctor and on careful and coordinated
sequencing of eventssequencing of events
Achieving a surgical margin that will ensure a low Achieving a surgical margin that will ensure a low
rate of local recurrence is paramount rate of local recurrence is paramount
Multidisciplinary approach is requiredMultidisciplinary approach is required