limb salvage principles in malignant bone sarcomas

1. PRINCIPLES OF LIMB SALVAGE SURGERY IN
RESPECT TO MALIGNANT BONE SARCOMAS
DR. HIMANSHU KANWAT
MODERATOR :
DR.VIKAS BACHHAL

3. HISTORICAL PERSPECTIVES
 Before 1970s, trans-bone amputations and disarticulations
were standard of treatment for osteosarcomas.
 Survival rates of only 10-20 %.
 Radiation therapy alone for ewing sarcoma with survival
rates of <20 %.
 Early trials of chemotherapy proved unsuccessful.
1.) Friedman MA, Carter SK. The therapy of osteogenic sarcoma: current status and thoughts for the future. J Surg Oncol. 1972;4:482–510.
2.) Phillips TL, Sheline GE. Radiation therapy of malignant bone tumors. Radiology. 1969;92:1537–45.

4.  In 1970s and 80s, effective chemotherapy regimes started to
develop.
 Adriamycin + high dose methotrexate showed better
outcomes in OS and Adriamycin based regimens in ES.
 Chemotherapy used to tackle micrometastases in form of
adjuvant therapy.
 MIOS trials for osteosarcoma corroborated poor outcomes
with surgery alone. (as compared to multimodal therapy).
1.)Saeter G, Alvegard TA, Elomaa I et al. Treatment of osteosarcoma of the extremities with the T-10 protocol, with emphasis on the effects of preoperative
chemotherapy with single-agent high-dose methotrexate: a Scandinavian Sarcoma Group study. J Clin Oncol. 1991;9: 1766–75.
2.) Nesbit ME, Gehan EA, Burgert EO et al. Multimodal therapy for the management of primary, nonmetastatic Ewing’s sarcoma of bone: a long-term follow-up of the
first intergroup study. J Clin Oncol. 1990;8:1664–74.
3.) Link MP, Goorin AM, Miser AW et al. The effect of adjuvant chemotherapy on relapse free survival in patients with osteosarcoma of the extremity. N Engl J Med.
1986;314:1600–6.

5.  Rosen et al introduced the concept of neo-adjuvant )
chemotherapy.
 With improvement in surgical techniques for limb salvage,
neoadjuvant chemo provided for pre-op down staging of
disease while the patient awaited surgery.
 Pediatric oncology group (POG) found no survival benefit of pre
op chemo over adjuvant chemo though pre-op chemo
provided a better chance to limb salvage.
 Some studies have shown better survival outcomes.
1.) Rosen G, Marcove RC, Caparros B. Primary osteosarcoma. The rationale for preoperative chemotherapy and delayed surgery. Cancer. 1979;43:2163–77.
2.) Priebat DA, Trehan PS, Malawer MM, Schulof RS. Induction chemotherapy for sarcomas of the extremities. In: Sugarbaker PH, Malawer MM, editors. Musculoskeletal
Surgery for Cancer. New York: Thieme; 1992:96–120.
3.) Goorin A, Schwartzentruber D, Gieser P et al. No evidence for improved event free survival with presurgical chemotherapy for non-metastatic extremity osteogenic
sarcoma: preliminary results of a randomized Pediatric Oncology Group trial (8651, an update). Med Ped Oncol. 1996;27:263.

6.  Advent of modern imaging modalities allowed better
understanding of tumor extent, presence of mets and better
staging of disease.
 Limb sparing resections were possible.
 Surgery proved to be better for ewing sarcoma than primary
radiotherapy.
 Development of modern reconstruction options like
endoprostheses furthered the drift toward limb salvage.
1.) Pritchard DJ. Surgical experience in the management of Ewing’s sarcoma of bone. Natl Cancer Inst Monogr. 1981;56:169–71.
2.) Toni A, Neff JR, Sudanese A et al. The role of surgical therapy in patients with nonmetastatic Ewing’s sarcoma of the limbs. Clin Orthop Rel Res. 1993;286:225–40.

7.  80% to 85% of patients with primary malignant bone tumors
involving the extremities can now be treated safely with
wide resection and limb preservation.
 Multi-modality treatment has increased survival rates to 60-
70%.
 Amputation and limb salvage provide similar survival benefit.
 Limb salvage is the current modality of surgical treatment for
all resectable bone sarcomas.
1.) Eilber FR, Eckhardt J, Morton DL: Advances in the treatment of sarcomas of the extremity: Current status of limb salvage. Cancer 1984;54(11 suppl): 2695-2701.
2.) Sluga M, Windhager R, Lang S, Heinzl H, Bielack S, Kotz R: Local and systemic control after ablative and limb sparing surgery in patients with osteosarcoma. Clin
Orthop 1999;358:120-127
3.) Sim, F. H.; Ivins, J. C.; Taylor, W. F.; and Chao, E. Y. S.: Limb-Sparing Surgery for Osteosarcoma: Mayo Clinic Experience. Cancer Treat. Sympos., 3: 139-154, 1985.

8. WHEN TO SALVAGE THE LIMB ??
All cases should be deemed amenable to limb salvage until
unless specific contra-indications are present.

9. INDICATIONS AND PRE-REQUISITES FOR LIMB
SALVAGE :
 Tumor can be resected with adequate margins.
 After resection the limb should have acceptable
function and cosmetic appearance as
compared to a prosthesis.
 Metastatic disease is not contraindication for
limb salvage. Metastatectomy can be
combined with limb salvage for better
outcomes.
 Tumor site : Upper limb salvage is always better
functionally than a prosthesis.

10.  Availability of adjuvant therapies in form of chemotherapy
and/or radiotherapy.
 It can even be considered in uncontrollable disease for relief
from pain, improved quality of life, and intact body image that
limb salvage can
offer, even if they may not survive long term.
 A motivated patient and family with adequate financial
resources. Amputation and chemotherapy is better option
than limb salvage and no chemo.
 A disease free survival is given preference over limb salvage
with doubtful tumor clearance.

11. BARRIERS TO LIMB SALVAGE :
 Major vascular involvement.
 Major motor nerve involvement
 Poorly placed biopsy incisions and drain tracts.
 Pathological fracture of involved bone
 Infection
 Inadequate motor components after resection
 Inadequate financial resources.

12.  These barriers are not absolute
contraindications for limb salvage.
Neurovascular grafts, tissue transfers for
coverage have allowed successful
salvage in presence of these barriers.

14. ALGORITHM FOR LIMB
SALVAGE PROCEDURES
THOROUGH
EVALUATION ,
PATIENT EDUCATION
AND TUMOR
STAGING
SURGICAL
RESECTION
BONY AND SOFT
TISSUE
RECONSTRUCTI
ON
NEOADJUVANT
CHEMOTHERAPY
ADJUVANT THERAPY FOR
PREVENTING SYSTEMIC
AND LOCAL RECURRENCE
REHABILITATION AND
MANAGING
COMPLICATIONS
TUMOR
RESTAGING

15. First step in management is reaching a
diagnosis

16. Clinical evaluation :
 History taking – temporal scale gives
an idea of aggressiveness of the
tumor. Local pain is m/c symptom.
Age at presentation.
 Examination – m/c sign is localized
swelling.
 Assess neurovascular involvement.
 Site of tumor – OS originates in
metaphysis, ES originates in diaphysis
m/c.

17. M/c sites for OS M/c sites for ewing
sarcoma

19. STAGING THE TUMOR :
This involves the use of modern
imaging and pathology to assess:
- Local spread
- Vital structure involvement
- Metastasis
- Margins for surgery
- Tumor grade and staging.

20. PLAIN X-RAYS
 Initial imaging modality.
 It confirms a bony lesion,
anatomical position and guides
further imaging.
 It can also be used to evaluate
effectiveness of chemotherapy
and lung metastases.
 Specific x ray features also point
towards the diagnosis.

21. Telangiectatic OS Parosteal OS Periosteal OS

22. Ewing sarcoma : permeative bone destruction with speculated or lamellar periosteal reaction.
Sclerotic lesion in pelvis

23. MAGNETIC RESONANCE IMAGING
 MRI has been found superior to CT in assessing the local
spread of malignant bone tumors.
 Imaging modality of choice.
 Evaluates extension into adjacent soft tissue, neurovascular
involvement, skip lesions, extension into adjacent joints and
longitudinal medullary extent of the tumor.
 Successful surgical resections have been possible only after
advent of MRI
1.) Berquist TH. Magnetic resonance imaging of primary skeletal neoplasms. Radiol Clin North Am.1993;31(2):411–24.
2.) Imaging Osteosarcoma Ali Nawaz Khan, Durr-e-Sabih, Klaus L. Irion, Hamdan AL-Jahdali and Koteyar Shyam Sunder Radha Krishna

24. Osteosarcoma distal femur Ewing sarcoma with
skip mets

25. MRI FOR STAGING THE TUMOR
 MRI superior to CT in evaluating
local spread.
 T1W1 images best depict the
local extent. The extent must
be defined with reference to
anatomical landmarks.
 Gadolinium contrast highlights
viable tumor tissue and can
guide biopsy sites avoiding
necrotic areas.
1.) Hogeboom WR, Hoekstra HJ, Mooyaart EL, et al. MRI or CT in the preoperative diagnosis of bone tumours. Eur J Surg Oncol. 1992;18(1):67–72.
CEMRI – non enhancing necrotic areas

26.  Physeal /epiphyseal
involvement preclude a joint
sparing surgery.
 With T1W1/ STIR, 60-70 % OS
have been shown to have
epiphyseal involvement.
 Muscular invasion with T1W1 /
Fat suppressed/T2SF –PD
sequences in axial planes.
1.) Manaster BJ, Petersilge CA, Roberts CC, Hanrahan CJ, Moore S (2010) Diagnostic Imaging: Musculoskeletal—Non-Traumatic Disease, 1st edn. Amirsys Publishing,
Philadelphia, pp 2-1 – 2-229
2.) Davies AM, Sundaram M, James SLJ. Imaging of Bone Tumors and Tumor-Like Lesions (Techniques and Applications) Berlin Heidelberg: Springer; 2009
Extension into epiphysis
Extension into joint space
with effusion

27.  MRI superior to conventional
angiography for nuero-vascular
involvement.
 Loss of perinueral/perivascular fat
or encasement (with or without
stenosis) is best predictor of nuero
– vascular involvement on T2FS /
CEMRI.
 Limited role in detecting lung and
bony metastases.
1.) Davies AM, Sundaram M, James SLJ. Imaging of Bone Tumors and Tumor-Like Lesions (Techniques and Applications) Berlin Heidelberg: Springer; 2009.
Involvement femoral vasculature.

28.  Identification of skip
metastases.
 Skip metastases change
the stage of the local
tumor (≥ IIIA) and hence
portend a poor prognosis.
 Trans-articular skips
considered stage 4 disease
should also be looked for.
1.) Manaster BJ, Petersilge CA, Roberts CC, Hanrahan CJ, Moore S (2010) Diagnostic Imaging: Musculoskeletal—Non-Traumatic Disease, 1st edn. Amirsys Publishing,
Philadelphia, pp 2-1 – 2-229
2.) he incidence and prognosis of osteosarcoma skip metastases.Sajadi KR, Heck RK, Neel MD, Rao BN, Daw N, Rodriguez-Galindo C, Hoffer FA, Stacy GS, Peabody TD,
Simon MA
Clin Orthop Relat Res. 2004 Sep; (426):92-6
3.) American Joint Committee on Cancer . AJCC Cancer Staging Manual. 7. New York Dordrecht Heidelberg London: Springer; 2010. pp. 279–290
Skips
lesions
detection
makes
the entire
bone
length to
be
assessed
by mri
along
with
adjacent
joints.

29. COMPUTED TOMOGRAPHY :
 Limited role for primary tumor.
 Useful for evaluating lung
metastases (CECT thorax).
 CT- guided biopsies.
Lung metastases seen on ct.
Lungs are the m/c site for
metastasis of bone
sarcomas.

30. BONE SCINTIGRAPHY :
 Before MRI, Bone scan was used for assessing intramedullary
extent.
 With MRI, it was found that Bone scan over-estimated the
intramedullary extent leading to radical resections.
 Currently, Bone scintigraphy is used to assess bony
metastases.
 It can be also be used to assess tumor response to
chemotherapy.
Bone and Soft-tissue Sarcomas: Epidemiology, Radiology, Pathology and Fundamentals of Surgical Treatment Barry Shmookler, Jacob Bickels, James Jelinek, Paul
Sugarbaker and Martin M. Malawer.

31. Bony metastases
seen on bone
scintigraphy

32. ANGIOGRAPHY :
 For evaluation of vascular
involvement.
 Vessel may be displaced,
encased or infiltrated with the
tumor.
 To decide whether to resect
vessel segment en-bloc or dissect
from tumor surface.
 Information regarding collaterals.
Vascular displacement

33. POSITRON EMMISSION
TOMOGRAPHY :
 tumor grading, staging, therapy
monitoring, and prognostication
in both adult and pediatric
populations.

34. BIOPSY
 Provides a tissue sample for
histologic diagnosis.
 Ultimate step in diagnostic
work-up

35. PRINCIPLES OF BIOPSY :
 Tertiary care centers.
 Adverse effects of performing biopsy at a
referral center are well documented :
 Higher rate of diagnostic inaccuracy (27% vs
12 %)
 Non-representative biopsy results (36% vs 4%)
 Alteration in treatment (36% vs 4%)
 Changes in outcome (17% vs 3.5%)
 FINAL STEP in the staging process
 By surgeon doing definitive Sx.
Mankin HJ, Mankin CJ, Simon MA. The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am. 1996;78:656-663.

36.  3 types of tissue sampling methods :
 FNAC – useful for identification of malignant cytological features
but doesn’t give enough tissue for study of architecture and is not
preffered for bone sarcomas.
 Core needle biopsy – Diagnostic accuracy of 76-88% and a
positive predictive value of 98%.
 Incisional biopsy - Best method. Provides adequate tissue for
histological analysis. Diagnostic accuracy of 96%.
Mitsuyoshi G, Naito N, Kawai A, et al. Accurate diagnosis of musculoskeletal lesions by core needle biopsy. J Surg Oncol. 2006;94:21-27

37. FNAC Core needle biopsy
Incisional biopsy

38.  Incision and drain site should be
planned in line with definitive
incisions as they have to be excised
en bloc.
 Should be performed at the edge
of the lesion to avoid necrotic
areas.
 No exsanguination if tourniquet is
used.
 Dissection should be though a single
muscle not muscle planes.

39.  Meticulous hemostasis : hematoma if
formed will be contaminated with
tumor.
 Drain should exit in line with the incision.
 Wound should be tightly closed in
layers.
Example of a properly placed
biopsy incision.

40. HISTOLOGIC ASPECTS
 Tumor grade.
 Histological subtype.
 Response to neo-
adjuvant
chemotherapy.
 This information has
bearing on the prognosis
of the disease.
Osteosarcoma
Ewing
sarcoma.

41. TUMOR STAGING
ENNEKING
CLASSIFICATION.

42. The New American Joint
Committee on Cancer Staging
System

43. PATIENT
EDUCATION
A well informed and motivated patient and family is most
important pre-requisite for limb salvage procedures to be
successful.

44. ROLE OF NEO-ADJUVANT AND ADJUVANT
THERAPY
 With advent of modern chemotherapeutic agents, long term survival for
bone sarcomas has become a reality augmenting the surgical therapies.
 The standard protocol for bone sarcomas include a period of pre-
operative chemotherapy followed by resection and a period of adjuvant
chemotherapy.
 This is based on studies conducted in 1970s and 80s ( Rosen et al., POG
trials, Rizzoli institute trials, MIOS group, MSKCC T 10 protocol, MDACC trials,
Benjamin et al. etc. )

45. Role of neo-adjuvant chemotherapy :
 Control of possible pulmonary
metastases (microscopic)
 Shrinkage in tumor size and vascularity.
 Forming a surrounding reactive rim that
helps in adequate resections with limb
salvage.
 Opportunity to test chemotherapeutic
response in resected tumor to guide
adjuvant therapy.
1.) Gherlinzoni M, Mercuri M, Avella M et al. Surgical implications of neoadjuvant chemotherapy: the experience at the Instituto Orthopedico Rizzoli in osteosarcoma
and malignant fibrous histiocytoma. In: Jacquillat C, Weil M, Khayat D, editors. Neoadjuvant Chemotherapy, vol. 169. John Libbey Eurotext, 1988: 541–4.
2.) Rosen G, Caparros B, Huvos AG et al. Preoperative chemotherapy for osteosarcoma. Selection of postoperative adjuvant chemotherapy based on response of
primary tumor to preoperative chemotherapy. Cancer. 1982;49:1221–39.
3.) Winkler K, Beron G, Delling G et al. Neoadjuvant chemotherapy of osteosarcoma: results of a randomized cooperative trial (COSS-82) with salvage chemotherapy
based on histological tumor response. J Clin Oncol. 1988;6:329–37.

46. Gauging the effect of neo-adjuvant therapy :
 Histologic response : Most important prognostic factor in bone
sarcomas.
 Clinically- reduction in pain, swelling.
 Radiologically – Reduction in size/disappearance of tumor.
Revisualization of fat planes, healing of pathological fractures.
 Reduction in titres of ALP, LDH in serum.
 Reduced vascularity on angiograms.
1.) Chuang VP, Wallace S, Benjamin RS et al. The therapy of osteosarcoma by intraarterial cisplatinum and limb preservation. Cardiovasc Intervent Radiol. 1981;4:229–35.
2.) Smith J, Heela RT, Huvos AG et al. Radiographic changes in primary osteogenic sarcoma following intensive chemotherapy. Radiology. 1982;145:355–60.
3.) Carrasco CH, Charnsangavej C, Raymond KA et al. Osteosarcoma: angiographic assessment of response to preoperative chemotherapy. Radiology. 1989;10: 839–42.

49. HUVOS GRADING SYSTEM
Grade Percentage of tumour necrosis
1 <50% of tumour is necrotic
2 Most of the tumour is necrotic <90%
3 Only occasional microscopic tumour viability
noted; 90–99% necrosis in each section
4 Tumour is totally necrotic
 Grade 1 and grade 2 imply poor response and the
tumor is likely to metastasize or recur after surgical
resection.
 Tailoring of adjuvant therapy may be required.
Huvos AG, Rosen G, Marcove R. Primary osteogenic sarcoma: pathologic aspects in 20 patients after treatment with chemotherapy, en bloc resection and
prosthetic bone replacement. Arch Pathol Lab Med. 1977;101:14–18.

50. ADJUVANT CHEMOTHERAPY :
 Includes the post operative chemotherapy regime.
 Poor prognosis with surgery/radiotherapy alone- a well known fact.
 Aimed at removing microscopic foci at local as well as distal sites (
Reduced incidence of pulmo mets . Jaffe et al .1983 )
 Post operative chemotherapy associated with survival rates of 60-70% in
high grade bone sarcomas.
 No role in low grade sarcomas like parosteal OS.
1.) Bramwell VHC. The role of chemotherapy in osteogenic sarcoma. Crit Rev Oncol/Hematol. 1995;20:61–85.
2.) Eilber FR, Rosen G. Adjuvant chemotherapy for osteosarcoma. Sem Oncol. 1989;16:312–23.

51. COMMONLY USED PROTOCOLS :
 Osteosarcoma (high grade) :
Neoadjuvant – Adriamycin + cisplatin + high dose methotrexate (3-6
cycles)
Adjuvant – in case of good response, same drugs 6 cycles post op.
in case of poor response – addition of ifosfamide
recommended.
 Ewing sarcoma :
Neoadjuvant and adjuvant - VAC IE (vincristine, Adriamycin,
cyclophosphamide + etoposide and ifosfamide ). For a total of 30 cycles.
Mayo clinic trial, MIOS trial , UCLA trial , Rizzolli institute trial , COSS 86 regimens. Bacci et al.

52. SURGICAL RESECTION
 Adequate margins
 Extensile exposures
 Nuero-vascular dissection
 Reconstruction of defects
 Soft tissue coverage.

53. MARGINS
RESECTION MARGINS :
 Intralesional/debulking
 Marginal – pericapsular reactive zone
 Wide > inadequate – 1cm normal tissue
adequate – 2-4 cm normal tissue
 Curative margins - > 5 cm of normal tissue
Frozen sections to confirms tumor free margins
and if found positive further resection/
amputation must be carried out.
Japanese Orthopaedic Association Musculoskeletal Tumor Committee.Evaluation Method of Surgical Margin for Musculoskeletal Sarcoma. In:JOA
Musculoskeletal Committee (ed). Evaluation Method of SurgicalMargin for Musculoskeletal Sarcoma. Ed 1. Tokyo: Kanehara;1989:3–22

54. CONCEPT OF NORMAL TISSUE IN WIDE MARGINS
 The extent of normal tissue to be removed differs acc to what constitutes
the margin.
 A bone margin of 3cm from medullary extent is acceptable for OS.
 Margins are defined acc to the presence of a barrier to tumor spread
present in the margins.
 Barriers can be thick or thin :
• Thick – strong membranous tissue like growth plate, joint capsule,
tendons, pediatric periosteum.
• Thin – Muscle fascia, vascular sheath , epineurium, adult periosteum.
The concept of curative margin in surgery for bone and soft tissue sarcoma. Kawaguchi N1, Ahmed AR, Matsumoto S, Manabe J, Matsushita Y. Clin Orthop Relat
Res. 2004 Feb;(419):165-72

55.  Thick barrier = 3cm
 thin barrier = 2cm
 Cartilage = 5cm
 The surgery is defined according to
the narrowest margin.
 Marginal margins for NVB
acceptable.
 Use of intra-op frozen section is
mandatory for defining the margins.
The concept of curative margin in surgery for bone and soft tissue sarcoma. Kawaguchi N1, Ahmed AR, Matsumoto S, Manabe J, Matsushita Y. Clin Orthop
Relat Res. 2004 Feb;(419):165-72

56. RECOMMENDATIONS OF Japanese Orthopaedic Association
Musculoskeletal Tumor Committee, 1989
GOOD RESPONSE TO PRE-OP THERAPY --- 2cm wide
margins
No pre-op therapy ---- 3cm wide margins
Nuerovascular bundles ---- marginal margins
Recurrent disease or poor response to preop therapy ---
curative margins

57. TYPES OF SURGICALS RESECTION:
Depends upon the location of tumor and
the involvement of adjacent joints –
 Intra-articular resection – if the joint is
not involved
 Extra- articular – Joint involvement
present.
 Intercalary resection- for diaphyseal
lesions.
It is imperative to excise biopsy tract
en bloc with the tumor
Intercalary resections :
Epiphysio-diaphyseal
Metaphysio-diaphyseal
Purely diaphyseal

58. INTRA-ARTICULAR RESECTION OF
PROXIMAL HUMERUS OS
EXTRA-ARTICULAR
RESECTION OF DISTAL
FEMUR OS

59. RECONSTRUCTION
The type of reconstruction will depend upon the defect
created after successful tumor resection with acceptable
margins.
HEMICORTICAL DEFECT :
low grade malignancies (eg. Parosteal OS)
This defect can be filled with a shaped allograft,
Fibula or iliac crest strut graft.
Because of large surface area and vascularity of the
Bed usual complications of allograft like non-union are
Rare.

60. FULL-SEGMENT DEFECTS : these can be joint involving or
intercalary.
Joint involving defects : m/c after resection of
metaphyseal tumors like OS.
Reconstruction options –
 Megaprostheses
 Osteo-articular allografts
 Allo-prosthetic composites
 Resection arthrodesis
 Rotationplasty

61. MEGAPROSTHESIS :
 Large metallic joint to replace the
excised bone and adjacent joint.
 Fully constrained hinge joints.
 Custom made and modular systems
both available.
 Sites available for reattachment of
tendons for functional superiority.
 Complete bone replacement
possible with these endoprostheses.
 Adequate soft tissue coverage is
essential over the implanted
prosthesis.

62. RESECTION AND
RECONSTRUCTION AROUND
THE ELBOW

63. Advantages :
 Immediate return to function.
 Not affected by adjuvant chemoradiation.
 Strong and sturdy implants.
 Modular systems allow for intra-op flexibility.
 Expandable prostheses are available for
pediatric population to manage resulting limb
length discrepancy with growth of the child.
Disadvantages :
 Infection
 Aseptic/septic loosening.
 Breakage
 Wear of bearing sufaces.
 Revision surgery when required is complex.

64. OSTEOARTICULAR ALLOGRAFTS :
 Sized osteoarticular allografts aims at
replacing the excised bone and joint with
biologic material.
 Advantages :
 Preservation of physis.
 Biological bed for soft tissue anchorage.
 Attachment of muscle insertions more successful than
metallic prosthesis.
 Long term success rate of 70%
Disadvantages :
 Non-union (15-20%)
 Infection(5-10%)
 Fracture(15-20%)
 Osteoarthritis.
 Non vascularization of graft.

65. ALLO-PROSTHETIC COMPOSITES :
 Appropriate sized allograft selected
and articular surface removed and
replaced like in standard joint
replacement.
 Advantages :
 Allograft provides for soft-tissue anchorage.
 Prosthesis provides a stable mobile joint.
 Not susceptible for osteo-arthritis.
 Lower fracture rates than allograft alone.
 Useful in situations where remaining proximal host
bone is inadequate to accept prosthesis stem.

66. RESECTION ARTHRODESIS :
 Practical low cost procedure
 Surgery involves joint immobilization with auto/allografts and
internal fixation.
 Autografts (vascularized/non-vascularized fibula) have better
outcomes than allografts.
 Internal fixation includes a long plate, locking nail.
 Distraction osteogenesis with ilizarov can also be used.
 Advantages : low cost, withstanding heavy manual activity.
 Disadvantages include prolonged immobilization , non union,
infection, difficulty in squatting, sitting in vehicles (in case of
knee arthrodesis).

68. ENNEKING
TECHNIQUE OF
RESECTION
ARTHRODESIS
AROUND SHOULDER

69. ROTATIONPLASTY :
 This procedure allows the ankle to
replace as knee after 180 degree
rotation of the limb.
 Salzer, 1974 in malignancies around
knee.
 Tibia is fused with proximal femoral
remnant placing ankle at the level of
knee to mimic the function of knee.
 External prosthesis

70. ADVANTAGES :
 Low cost
 Straightforward procedure – can be done in hospitals
with less infrastructure.
 No revisions necessary.
 Allows adjusting the stump length for growth.
 Pt. able to participate in outdoor sports activities and
able to load the limb.
 Less pain. No phantom pain since sole is the weight
bearing area.
 Good functional outcome in large tumors involving
quadriceps extensively.
 Excellent salvage procedure for failed prosthesis.
DISADVANTAGES :
Cosmetically less appealing.

71. INTERCALARY DEFECTS:
These defects are m/c seen in tumors involving the diaphysis
with variable extension into metaphysis. (EWING SARCOMA)
Intercalary defects can be 3 types – Epiphysiodiaphyseal,
metaphysiodiaphyseal or purely diaphyseal
Reconstruction options involve :
 Allografts and autografts
 Endoprostheses
 Re-implantation of tumor bone after ECRT.

72. Autografts and allografts :
 Allografts have disadvantages of non-union, infection,
fracture.
 Autografts used can be vascularized or non-vascularized
fibula (better union rates than allografts).
 Single fibula prone to fracture in gaps >20cm.
 Allografts can be used in combination with VF/NVF as
intramedullary or onlay graft with internal fixation to overcome
disadvantages of either.

74. RE-IMPLANTATION OF TUMOUR BEARING BONE:
The resected bone can be used for re-implantation after
treatment for killing tumor cells :
- Autoclaving – associated with loss of strength and osteoinductivity
- Liquid nitrogen
- Pastuerzation – Results comparable to allografts.
- Extra-corporeal RT (5000Gy) – Non-union rates of 7% significantly lower
than in allografts (43%). Fracture rates are similar and very less
incidence of infection.
Like allografts, VF/NVF augmentation can be used to enhance
results.

75. SOFT TISSUE RECONSTRUCTION :
 Primary closure
 Skin grafts/ musculocutaneous
flaps
 Nerve grafts
 Vascular grafts

76. GENERAL COMPLICATIONS OF LIMB SALVAGE SURGERIES :
 Recurrence
 Infection
 Severe blood loss
 Complications related to prolonged surgery and excessive
tissue handling (atelectasis, hyperkalemia etc).
 Necrosis of skin flaps.
 Loosening of prostheses requiring revision surgery.
 Life style and activity level modification
 High cost.

78. CONCLUSION
Except for tumors presenting with fungating masses,
limb salvage procedures can be undertaken for
majority of tumors with adequate planning and
adjuvant therapies like chemoradiation.
A properly educated patient and a well planned
surgeon make treatment of bone sarcomas not so
dismal an enterprise.

79. THANK YOU