Various Methods of Limb Salvage in Orthopaedics

1. Department of Orthopaedics
MH Kirkee
SEMINAR
LIMB SALVAGE
Maj Rohit Vikas
Resident

2. LIMB SALVAGE
INTRODUCTION

3. 1970s amputation was
standard treatment

10. LIMB SALVAGE
PRINCIPLES

11. COMPARED WITH AMPUTATION AND PROSTHETIC REHABILITATION
SURVIVAL
RECURRENCE
Oscar Pistorius FUNCTION
DURABILITY
COMPLICATIONS
NEOADJUVANT CHEMOTHERAPY

13. CONTRAINDICATIONS
BARRIERS TO LIMB SALVAGE
Relative Contraindications to Limb-Sparing Procedures
Major neurovascular structures encased by tumor when vascular bypass is not feasible
Pathologic fracture with hematoma violating compartment boundary
Inappropriately performed biopsy or biopsy-site complications
Severe infection in the surgical field
Immature skeletal age with predicted leg-length discrepancy >8 cm
Extensive muscle or soft-tissue involvement
Poor response to preoperative chemotherapy

14. Clinical Evaluation
Pre Op Staging
Biopsy Principles
Neoadjuvant Chemotherapy
Tumour Resection
Avoiding local recurrence is the criterion of success
Wide Resection
En bloc removal of all biopsy sites contaminated tissue
Adequate margins
Resection of bone 3 to 4 cm beyond abnormal uptake
Frozen Section
Skeletal Reconstruction
Reconstruction of Soft Tissue and Wound Cover
Post op Chemotherapy

15. LIMB SALVAGE
RESECTION ARTHRODESIS

16. EXTERNAL FIXATOR
INTRAMEDULLARY NAIL
BONE GRAFTS
INTERNAL FIXATION
Dual fibular autografts

18. Chondrosarcoma, primary central -
Distal femur

21. LIMB SALVAGE
RESECTION + RECONSTRUCTION
AUTOGRAFT

22. LIMB SALVAGE
RESECTION + RECONSTRUCTION
BONE CEMENT

24. LIMB SALVAGE
RESECTION + RECONSTRUCTION
ALLOGRAFT

25. INTERCALARY ALLOGRAFT RECONSTRUCTION
Disadvantages
High rates of
infection, nonunion, # of
allograft.
Adjuvant chemo slows
allograft incorporation
Transmission of
infections
Slow remodelling –
hardware used cannot be
removed
80% good results

27. Osteoid Osteoma +
Osteogenic sarcoma, intracortical - Femur

28. osteoid-forming tumor being produced by
osteoblastic cells with a low mitotic index
without an aggressive pattern. This is
compatible with the diagnosis of osteoid
osteoma

29. Painful recurrence with a lytic area twice
as large as the original nidus.

30. A neoplastic osteoid formation
by osteoblastic cells that have
the appearance of an low grade
osteosarcoma.

31. Cortical allograft in position following
resection of 70% of the diaphysis of the
femur with a side plate for stability.

32. Osteogenic sarcoma, intracortical -
Distal humerus

34. Wide resection of the distal portion of the
humeral diaphysis was carried out, leaving the
elbow joint intact.
The defect was reconstructed with an allograft
fixed into postion with a recon plate.
ADVANTAGES
Availability in all sizes and shapes
Progressive incorporation into host bone
Conventional arthroplasty instead of custom made
prosthesis
Attachment sites available for resected muscles and
joint stabilisers – better function
No donor site morbidity
Failed allograft – further options available

35. OSTEOARTICULAR ALLOGRAFT RECONSTRUCTION

36. GCT – Extended Curettage + PMMA Replaced with a hemicondylar
Lateral compartment degeneration osteoarticular allograft.

37. LIMB SALVAGE
RESECTION + RECONSTRUCTION
VASCULARISED BONE GRAFT

39. GCT

40. Radiation associated ST # Femur with Nonunion managed with Vascularised fibular Graft

41. LIMB SALVAGE
RESECTION + RECONSTRUCTION
PROSTHESIS

42. PROSTHETIC RECONSTRUCTION
• Advantage – earliest mobilisation and weight bearing
• 10-year survival of modular prosthesis for
– Distal femur – 90%.
– Proximal humerus – 98%.
– Proximal femur – 100%.
– Proximal tibia – 78%.

44. ONCO PROSTHESIS FOR PROXIMAL FEMUR
Fibrosarcoma - Femur

45. ONCO PROSTHESIS FOR PROXIMAL FEMUR
Fibrosarcoma - Femur

46. ONCO PROSTHESIS FOR PROXIMAL FEMUR
Fibrosarcoma - Femur

47. ONCO PROSTHESIS FOR PROXIMAL FEMUR
Fibrosarcoma - Femur

48. ONCO PROSTHESIS FOR PROXIMAL FEMUR
Fibrosarcoma - Femur

49. ONCO PROSTHESIS FOR PROXIMAL FEMUR
Radiation associated Fracture of Proximal Femur

50. ONCO PROSTHESIS FOR DISTAL FEMUR
Osteosarcoma - Femur

51. ONCO PROSTHESIS FOR DISTAL FEMUR
Osteosarcoma - Femur

52. ONCO PROSTHESIS FOR DISTAL FEMUR
Osteosarcoma - Femur

53. ONCO PROSTHESIS FOR DISTAL FEMUR
Osteosarcoma - Femur

54. ONCO PROSTHESIS FOR DISTAL FEMUR
Osteosarcoma - Femur

55. ONCO PROSTHESIS FOR DISTAL FEMUR
Osteosarcoma - Femur

56. ONCO PROSTHESIS FOR DISTAL FEMUR
Chondrosarcoma – Dedifferentiated ,Femur

57. ONCO PROSTHESIS FOR DISTAL FEMUR

58. ONCO PROSTHESIS FOR DISTAL FEMUR

59. ONCO PROSTHESIS FOR DISTAL FEMUR

60. ONCO PROSTHESIS FOR DISTAL FEMUR
Recalcitrant Non union of Radiation associated Fracture SC Femur

61. ONCO PROSTHESIS FOR DISTAL FEMUR
TMH-NICE
(New Indigenous Customised
Endoprosthesis)joint

62. ONCO PROSTHESIS FOR PROXIMAL HUMERUS

63. Osteosarcoma of scapula. Unconstrained total scapular prosthesis with cemented
humeral component used for limb salvage.

64. SADDLE PROSTHESIS
MARK II

65. LIMB SALVAGE
RESECTION + RECONSTRUCTION
ALLOGRAFT PROSTHESIS COMPOSITE
Attachment sites available for resected
muscles and joint stabilisers – better function

68. Combined allograft and
cemented Neer prosthesis

71. Low-grade cartilaginous tumor but with areas in the central portion that show osteoid
being produced by the tumor as well

72. Osteogenic sarcoma, periosteal -
Proximal tibia

73. A total knee implant with an allograft placed over the
proximal portion of the tibial component and a short
side plate to control rotation of the allograft.

74. Restoring bone stock
Preventing loosening by increasing interface
surface between prosthesis and bone
Limiting proximal bone resorption

75. LIMB SALVAGE
RESECTION + RECONSTRUCTION
AUTOCLAVED BONE GRAFT +/-
PROSTHESIS

76. Malignant fibrous histiocytoma - Proximal
humerus

79. Part of the reconstructive procedure
consists of autoclaving the surgical
specimen at 130 degrees centigrade
for 4 min.
This kills the tumor but preserves
the physical aspects of the
bone, which is then placed back
over a long-stem Neer prosthesis
and cemented into position.

85. Acetabulum following the resection
showing the hyperemic changes in the
acetabular synovial tissues, a response
to the antigen stimulation of the
nearby tumor in the upper femur.
There is no crossover into the
acetabular structures preventing the
need for a more aggressive internal
hemipelvectomy reconstruction.

88. Osteogenic sarcoma, classic - Pelvis

89. Internal hemipelvectomy
The specimen was debulked of the major tumor
mass which was sent to pathology.
The remaining bone was placed in the autoclave
for 5 minutes at 130°C and placed back into the
patient's pelvis for reconstructive purposes.

90. Pins were placed through the autoclaved autograft along with
screws and plates.
A routine total hip prosthesis was cemented into position on Entire acetabulum recemented in anatomical position that
top of the threaded Steinmann pins. allows for excellent weight bearing function

92. LIMB SALVAGE
RESECTION + RECONSTRUCTION
TOTAL FEMUR

93. Ewing's sarcoma – Femur With Pathological fracture from biopsy site

97. Custom total femoral implant

98. LIMB SALVAGE
RESECTION + RECONSTRUCTION
ROTATIONPLASTY

99. ROTATIONPLASTY
• Group AI— Distal Femur.

100. ROTATIONPLASTY
• Group AII—Proximal Tibia.

101. ROTATIONPLASTY
• Group BI— Proximal Femur sparing the hip joint and gluteal muscles.

102. ROTATIONPLASTY
• Group BII— Proximal Femur with involvement of hip joint and
contiguous soft tissue.

103. ROTATIONPLASTY
• Group BIII—Lesion in midfemur.

104. ROTATIONPLASTY
Borggreve-Van Nes rotationplasty

105. ROTATIONPLASTY

106. ROTATIONPLASTY

107. ROTATIONPLASTY

108. ROTATIONPLASTY

109. Osteogenic sarcoma, classic
07y/ M

111. A modified amputation by means of a Van Ness turn-up-plasty.
Bone amputation level is high above the tumor in the proximal femur but the soft tissue
amputation is distal just above the knee, utilizing the proximal tibia as a vascularized graft.
The tibia is turned upside down into the defect created by the bone resection, leaving the
patient with a functional end result similar to a routine supracondylar amputation.
Traditional design of the skin flaps for a supracondylar amputation.

112. The proximal 10 inches of the tibia has been mobilized from its surrounding soft
tissue, leaving only the anterior compartment and the deep posterior compartment
intact. The popliteal vessels are intact proximally just beneath the tibial plateau, still
supplying vascular nutrition to the resected tibia.

113. The surgeon has placed the proximal 10
inches of the tibia upside down into the
thigh with a sideplate utililized
proximally to fix the distal part of the
tibia to the proximal part of the femur.
We are looking directly at the tibial
plateau surface of the knee joint that
now acts as the distal end of the
femoral stump to replace the resected
distal femur.
The resected distal femur and its tumor
content is seen lying next to the
wound.

115. LIMB SALVAGE
RESECTION +
LIMB LENGTHENING

117. BONE TRANSPORT

118. BONE TRANSPORT

119. LIMB SALVAGE
COMPOSITE TISSUE
ALLOGRAFT

120. COMPOSITE TISSUE ALLOGRAFT
First hand transplant by Dubernard et al in 1998
More than 100 CTA transplantations have been performed since 1998
These transplantations have included the upper extremity, laryngeal tissue, abdominal
wall, face, bone, joint, uterus, nerve, tongue, and genitals.
Still an experimental reconstructive procedure.

121. COMPOSITE TISSUE ALLOGRAFT
Skin - most antigenic and immunoreactive tissue in CTA

122. COMPOSITE TISSUE ALLOGRAFT
In the United States, 5 hands have been transplanted in five patients since 1999
at the University of Louisville
3 hands have been transplanted in two patients at the University of Pittsburgh
Medical Center in 2009.
Composite Tissue Allotransplantation. Available at: http://www.handtransplant.com/. Accessed December 30,2009.
Successful Hand Transplants Performed. Available at: http://www.mirm.pitt.edu/ news/article.asp?qEmpID=434. Accessed
December 30, 2009.

123. LIMB SALVAGE
IN CHILDREN

124. LIMB SALVAGE IN CHILDREN
• Biologic
– Allografts, vascularised autografts
– Best for diaphyseal defects but not osteoarticular defects
• Nonbiologic
– Using a prosthesis
– Early weight bearing, joint motion
– Expensive ,Complications increase with survival
• Combined (biologic and nonbiologic).

125. LIMB SALVAGE IN CHILDREN
Expandable prosthesis
• Restoration of limb length desirable
– Lower limb
• Gait abnormalities, leg pain, and back pain
– Upper limb
• short arm is cosmetically embarrassing

126. The leg was gradually
lengthened by
inserting and turning
with a metal key via a
one centimetre skin
incision.
Expandable custom-
made tumour
prosthesis.

127. Electromagnetic external drive machine

128. LIMB SALVAGE IN CHILDREN
– Extendable prostheses required when
• Estimated leg-length discrepancy at skeletal maturity is
more than 3 cm / when the arm-length discrepancy is
more than 5 cm.
– Girls older than 11 years or boys older than 13
years rarely require extendable prostheses

129. LIMB SALVAGE
RESULTS

130. CLINICAL RESULTS
• Nonmetastatic osteosarcoma of distal femur
– 11% recurrence with limb salvage
– 8% recurrence with AK amputation
– No recurrence after hip disarticulation
• Rate of local recurrence
– 8% for poor histologic responders
– 3% for good histologic responders
• Most important determinant of local recurrence was the type
of surgical margin and the response to chemotherapy.

131. ADVANCES
• Use of bio artificial Hydroxyapatite – fixation of bone cells on HA-can be
used in lieu of autografts
• Osteointegrable prosthesis
– Osteoinduction by BMP
– Biodegradable synthetic carrier – Polylactate-Polyethylene glycol (PLA-
PEG)
• Dacron fabric enveloped alumina ceramic prosthesis for large bone
defects – for better ancourage of soft tissues
• IM nailing instead of plating for fixation of allografts (Endolock, Titanium
Dynamic nailing)