SURGICAL ASPECTS OF OSTEOSARCOMA “CROUCHING TUMOUR HIDDEN SURGEON” DR.R.PRABHA RAMKUMAR. MS ORTHOPAEDIC SURGERY EMAIL : [email protected]
Transcript
1. CROUCHING TUMOUR HIDDEN SURGEON DR.R.PRABHA RAMKUMAR. MS
ORTHOPAEDIC SURGERY EMAIL : [email protected]
2. BEFORE Before the advent of chemotherapy and appropriate
surgical techniques like CMP the prognosis of osteosarcoma was
dismal. Most patients are treated with Wide or Radical amputation.
But most patients died of distant metastasis (80%)
3. AFTER With todays multiagent chemo and appropriate surgical
techniques, long term survival of 60-70% for high grade without
metastasis at initial presentation and 90% for low grade is
possible.
4. OUTCOME RESTS ON Extent of the disease Grade of the lesion
Size of the primary lesion Site and location of the lesion
(proximal>distal) Secondary metastasis 20% have at intial
presentation Pulmonary and non pulmonary metastasis Time of
diagnosis Resectable and Non resectable tumours Skip lesions same
like metastasis Radiation induced Osteosarcomas (? Due to unusual
unresectable sites)
5. PROTOCOL 1 CLINICAL/RADIOLOGICAL EVALUATION 2 BIOPSY
HISTOPAYHOLOGICAL CONFIRMATION 3 NEO ADJUVANT CHEMOTHERAPY 4
DEFINITIVE SURGERY 5 CHEMOTHERAPY AND REHABILITATION
6. Clinical and radiological imaging A thorough Clinical and
radiological evaluation is must Mainly to detect any occult
metastasis which will affect the treatment outcome. Staging of the
lesion and finding the lesion is intra or extra compartmental.
7. Bone scan
8. Biopsy and HPE examination Irrespective of imaging, a HPE
diagnosis is of essence FNAC is not used as it offers less
information Either a closed core biopsy or open biopsy is preffered
Various complications related to open biopsy are large scale
contamination of tissues, infection ,fracture Necrotic or heavily
calcified or ossified areas are avoided
9. Surgical METHODS Amputation/Disarticulation lesser post
operative morbidity but poor functional outcome
10. Limb Salvage-Wide excision with prosthetic augmentation or
reconstruction with bone grafts has greater peri operative
morbidity and good functional outcome. surgeries include -Resection
and arthrodesis/arthroplasty -Resection with distraction
osteogenesis -Resection and Prosthetic replacement/auto or
allograft
11. HOW TO DECIDE? If the tumor can be removed with an adequate
margin and the resulting limb has satisfactory function -LIMB
SALVAGE After salvage the limb should have an acceptable degree of
function and cosmetic appearance with a minimal amount of pain, and
should be capable of withstanding the demands of normal daily
activities
12. Four things to be considered , - Would survival be affected
by the treatment choice? - How do short term and long term
morbidity compare? - How do the function of a salvaged limb compare
with that of prosthesis? - Are there any psycho social
consequences?
13. Amputation/ Disarticulation For larger tumours where
recostruction and resection with wide margins not possible More
proximal tumours As a palliative measure for distant metastasis and
final stage for pain relief Level is according to the site of the
tumour and extent Locally recurrent Pathological fracture where
stabilisation not possible Malignancy with massive necrosis,
fungation, infection or vascular compromise.
14. our experience, 12 YEARS MALE
15. Rt leg
16. AFTER HIP DISARTICULATION
17. LIMB SALVAGE- a guardian angel? Can be done by- -Wide
excision and arthrodesis/arthroplasty - Wide excision with
distraction osteogenesis - Wide excision and Prosthetic
replacement. Studies shows no superiority of limb salvage to
amputation. For successful outcome it is essential to achieve a
complete resection of the tumor with an adequate margin(approx 3
cms from the extent from T1 MRI)
18. 3 stages Excision of tumour Reconstruction of the defect
Closure of the defect
19. Excision of tumour If the joint is not contaminated by the
tumor, an intraarticular resection is performed through the joint
If the joint is involved-an extraarticular excision, taking the
entire joint and joint capsule, and cutting through the uninvolved
bone on the other side of the joint for a wide margin The gap
remaining needs reconstruction either with metal or with bone or a
composite of the two For tumors that involve the diaphyseal portion
of a bone, an intercalary resection and reconstruction can be
performed that saves the joints at either end.
20. Good excision
21. It is now possible to save the joint even if only 1.5-2cms
of condyle thickness remain For low grade osteosarcoma, a
hemicortical excision which removes only a part of the bone
circumference is effective in disease control. The reconstruction
done often depends on the kind of defect. Hemicortical defects
result generally from partial circumferential excision of benign or
low grade tumors like a parosteal osteosarcoma.
22. Types of defects
23. FILLING OF DEFECTS
24. Reconstruction of resulting defect is must should allow
effective closure Can be done with a bone ,a metal implant or a
combo, Ilizarov using distraction osteogenesis is an alternative
eliminate potential dead space and transfer tissues if necessary.
Reconstruction or substitution of a segment of artery or nerve may
be required. M/C site is the metaphysis so typical resection
involves the whole proximal or distal part of the bone.
25. Types of defects
26. Joint involving large defects CUSTOM MEGAPROSTHESIS-
Megaprosthesis is a large metallic joint designed to replace the
excised length of bone and the adjacent joint. fully constrained
hinge joints not affected by ongoing adjuvant treatment like
chemotherapy and radiotherapy A customised joint has to be ordered
as per individual patients dimensions takes 4-6 weeks for
fabrication MODULAR PROSTHESIS - components are assembled.Allow for
immediate availability, also allow intraoperative flexibility. The
drawback is that they are expensive and a large inventory of the
components has to be kept
27. Currently modular systems are used for most adults and
children near skeletal maturity as adequate modularity ensures a
good fit into the defect for almost all patients. In children or in
places where anatomy is distorted, customized implants are used to
adjust for smaller or abnormal bone size and to allow
expansion.
28. custom mega prosthesis
29. Pre op planning for CMP
30. 45 years male
31. Post op
32. Modular prosthesis for distal femur
33. EXPANDABLE PROSTHESIS- for Managing limb length in young
children In children, the operated leg becomes shorter as the
normal leg continues to grow while the operated leg does not
resulted in limp and poor function could be lengthened periodically
(expandable prosthesis). The prosthesis has a worm gear mechanism
which allowed a telescoping cylinder to increase the length when a
screw was turned Need periodical surgeries Newer implants allow
lengthening by EM field to minimise surgeries
34. OSTEOARTICULAR ALLOGRAFTS- have shown a success rate of 70%
at long term follow-up have the advantage of providing biological
bed for soft tissue anchorage. The attachment of muscle insertions
is more successful in allografts than in prostheses, yielding
better function in some sites Rather than a biologic replacement it
acts as a biologic spacer. infection (5-15%), fracture (15-20%),
Non-union (15- 20%) and osteoarthritis from collapse of the
articular surface (with osteoarticular graft) can occur.
Chemotherapy and radiotherapy can adversely affect the union
rates
35. ALLOPROSTHETIC COMPOSITE - combination of allo graft and
endoprosthesis allograft is selected and implanted to replace the
segment of bone resected. The articular surfaces of the graft are
excised and replaced using conventional techniques of total joint
arthroplasty provides a source of bone stock and a site for tendon
insertions, while the prosthesis provides a reliable and stable
articulation has a lower fracture rate than allograft alone and is
not susceptible to osteoarthritis.
36. RESECTION ARTHRODESIS- though disabling can provide a
practical low cost option for reconstruction For pts engage in
heavy manual labour, not easily accepted bone grafts coupled with
internal fixation, very similar to those of intercalary resections.
Autografts vascularised or nonvascularisedare used along with
fixation which is either a locked long nail, or a long plate or
sometimes an external fixator We have used a double barrel live
fibula or an allograft combined with a live fibula and neutralized
with a plate A non vascularised graft always has the risk of
fracture
37. Fixation is either with a plate spanning the defect or with
a long customized nail Long time immobilisation
38. ROTATIONPLASTY-allows the ankle to substitute as the knee
after 180 degrees rotation of the limb Used in proximal focal
femoral deficiency limb continuity is established by fusing the
Tibia with the proximal femoral remnant functions like a below-knee
amputation there is no phantom pain as sole is normal weight
bearing area Psychological barrier
39. Pt can run, ride a bike etc
40. INTERCALARY DEFECTS Intercalary defects-classified as
diaphyseal, metaphyseo-diaphyseal, or epiphyseodiaphyseal
Intercalary allografts have shown higher success than the
osteoarticular ones Vascularised fibula (VF) is a good alternative
for intercalary defects especially for longer gaps. 93% union
rate
41. INTERCALARY DEFECTS Reimplantation of tumor bearing
bone-Reimplanting the tumor bearing bone after some form of
treatment (autoclaving, pasteurization, freezing with liquid
nitrogen, or extracorporeal radiation) to kill the tumor cells is
another exciting low cost option. Though dead like an allograft, it
is perfectly matched to the defect 12 cases from Pakistan showed
good with only one non- union High temperatures can cause bone
weakening hence Pasteurisation ( heating the bone to 60 deg C for
30 min in a water bath ) is preferred Extracorporeal irradiation is
equally effective
42. Reimplantation after radiation
43. INTERCALARY DEFECTS PROSTHESIS- also be used to reconstruct
non-joint defects can be used as physis sparing or joint saving
implants avoids the donor site morbidity of autograft and the
fracture and non-union risk of allograft especially for patients on
chemotherapy shortens surgical time compared to grafting higher
rate of loosening is due to rotational stress aseptic loosening may
be reduced with hydroxyapatite (HA) or porous titanium bead
coating
44. INTERCALARY DEFECTS
45. OUR EXPERIENCE , 14 years male
46. DIATRACTION OSTEOGENESIS
47. OSTEOSARCOMA OF PELVIS challenge to an orthopaedic
oncologist Tumors are often large at presentation and do not always
respond well to the preoperative chemotherapy The surgery is
extensive and has the potential for many complications. An external
hemipelvectomy has therefore been the standard of care in the past
Though it causes major disfigurement and extensive functional
handicap, it was the safest way of getting a chance of cure in a
pelvic osteosarcoma
48. Limb saving resections have now become feasible and are the
standard of care. Pelvic resections are any one or the combination
of the following four types Type I (Iliac), Type II
(periacetabular), Type3 (anterior arch) and typeIV (sacrum)
internal hemipelvectomy- resection of the entire hemipelvis from
the SI joint to the pubic symphysis. Today, the term has come to
include resections of the pelvis which include the acetabulum with
varying portions of the Ilium & the anterior arch
49. Resections involving the acetabulum leave behind
significantly more instability than the other types of partial
pelvic resections. reconstruction using -arthodesis (iliofemoral
and ischiofemoral fusion), - surgical pseudarthrosis (mesh
reconstruction), -pelvic allografts, - custom-made endoprostheses,
the saddle prosthesis - reimplantation of the excised hemipelvis
after sterilisation by radiation have been used with better
cosmetic and functional results
50. Tumors located near the sacroiliac joints or pubic
symphysis present a special problem in that positive margins of
resection may occur unless the procedure is extended to the sacral
ala or the contralateral side of the symphysis, respectively
Induction chemotherapy may be useful to shrink these tumors prior
to their surgical removal
51. Ilio femoral fusion
52. Reconstruction by custom acetabular prosthesis
53. Our experience, 22 years male
54. Hemipelvectomy x ray
55. Limb salvage-disadvantages Limb salvage is a more extensive
surgical procedure with increased the risk of - Infection - wound
dehiscence and flap necrosis - Blood loss - DVT - local recurrence
- peri prosthetic fractures/ implant loosening -Graft host
rejection -Allograft fracture - Leg length discrepancy - multiple
subsequent surgery But Despite of all this it has better post
operative functional outcome.
56. Final word ideal situation is when the disease can be
successfully removed without an amputation and the resulting loss
of bone and muscle compensated by a method which retains near
normal limb function. Patient survivals have dramatically improved
following the availability of newer chemotherapy drugs and this has
accentuated the need for durable methods of reconstruction of large
musculoskeletal defects Ever increasing advances in technology and
biomaterials combined with a better understanding of biomechanics
will further help in increasing the durability of and refining limb
salvage procedures