Limb salvage in musculoskeletal oncology: Recent advances

ABSTRACT

The treatment of musculoskeletal sarcomas has made vast strides in the last few decades. From an era where amputation was the only option to the current day function preserving resections and complex reconstructions has been a major advance. The objectives of extremity reconstruction after oncologic resection include providing skeletal stability where necessary, adequate wound coverage to allow early subsequent adjuvant therapy, optimising the aesthetic outcome and preservation of functional capability with early return to function. This article highlights the concepts of surgical margins in oncology, discusses the principles governing safe surgical resection in these tumors and summarises the current modalities and recent developments relevant to reconstruction after limb salvage. The rationale of choice of a particular resection modality, the unique challenges of reconstruction in skeletally immature individuals and the impact of adjuvant modalities like chemotherapy and radiotherapy on surgical outcomes are also discussed.

KEY WORDS

Bone tumor - reconstruction - sarcoma

• REFERENCES

• 1 Mason GE, Aung L, Gall S, Meyers PA, Butler R, Krüg S. et al. Quality of life following amputation or limb preservation in patients with lower extremity bone sarcoma. Front Oncol 2013; 3: 210
• 2 Kawaguchi N, Ahmed AR, Matsumoto S, Manabe J, Matsushita Y. The concept of curative margin in surgery for bone and soft tissue sarcoma. Clin Orthop Relat Res 2004; 419: 165-72
• 3 Pollock RC, Stalley PD. Biopsy of musculoskeletal tumours - beware. ANZ J Surg 2004; 74: 516-9
• 4 Jeys LM, Luscombe JS, Grimer RJ, Abudu A, Tillman RM, Carter SR. The risks and benefits of radiotherapy with massive endoprosthetic replacement. J Bone Joint Surg Br 2007; 89: 1352-5
• 5 Gosheger G, Gebert C, Ahrens H, Streitbuerger A, Winkelmann W, Hardes J. Endoprosthetic reconstruction in 250 patients with sarcoma. Clin Orthop Relat Res 2006; 450: 164-71
• 6 Tang X, Guo W, Yang R, Tang S, Yang Y. Custom-made prosthesis replacement for reconstruction of elbow after tumor resection. J Shoulder Elbow Surg 2009; 18: 796-803
• 7 Natarajan MV, Sivaseelam A, Ayyappan S, Bose JC, Sampath Kumar M. Distal femoral tumours treated by resection and custom mega-prosthetic replacement. Int Orthop 2005; 29: 309-13
• 8 Puri A, Gulia A. The results of total humeral replacement following excision for primary bone tumour. J Bone Joint Surg Br 2012; 94: 1277-81
• 9 Puri A, Gulia A, Chan WH. Functional and oncologic outcomes after excision of the total femur in primary bone tumors: Results with a low cost total femur prosthesis. Indian J Orthop 2012; 46: 470-4
• 10 Donati D, Colangeli M, Colangeli S, Di Bella C, Mercuri M. Allograft-prosthetic composite in the proximal tibia after bone tumor resection. Clin Orthop Relat Res 2008; 466: 459-65
• 11 Li J, Wang Z, Guo Z, Chen GJ, Yang M, Pei GX. Irregular osteotomy in limb salvage for juxta-articular osteosarcoma under computer-assisted navigation. J Surg Oncol 2012; 106: 411-6
• 12 Li J, Wang Z, Guo Z, Chen GJ, Yang M, Pei GX. Precise resection and biological reconstruction under navigation guidance for young patients with juxta-articular bone sarcoma in lower extremity: Preliminary report. J Pediatr Orthop 2014; 34: 101-8
• 13 Kim JH, Kang HG, Kim HS. MRI-guided navigation surgery with temporary implantable bone markers in limb salvage for sarcoma. Clin Orthop Relat Res 2010; 468: 2211-7
• 14 Wong KC, Kumta SM, Sze KY, Wong CM. Use of a patient-specific CAD/CAM surgical jig in extremity bone tumor resection and custom prosthetic reconstruction. Comput Aided Surg 2012; 17: 284-93
• 15 Pilge H, Gradl G, von Eisenhart-Rothe R, Gollwitzer H. Incidence and outcome after infection of megaprostheses. Hip Int 2012; 22 (Suppl. 08) S83-90
• 16 Tsuchiya H, Shirai T, Nishida H, Murakami H, Kabata T, Yamamoto N. et al. Innovative antimicrobial coating of titanium implants with iodine. J Orthop Sci 2012; 17: 595-604
• 17 Hussmann B, Johann I, Kauther MD, Landgraeber S, Jäger M, Lendemans S. Measurement of the silver ion concentration in wound fluids after implantation of silver-coated megaprostheses: Correlation with the clinical outcome. Biomed Res Int 2013; 2013: 763096
• 18 Hardes J, von Eiff C, Streitbuerger A, Balke M, Budny T, Henrichs MP. et al. Reduction of periprosthetic infection with silver-coated megaprostheses in patients with bone sarcoma. J Surg Oncol 2010; 101: 389-95
• 19 Erdmann D, Garcia RM, Blueschke G, Brigman BE, Levin LS. Vascularized fibula-based physis transfer for pediatric proximal humerus reconstruction. Plast Reconstr Surg 2013; 132: 281e-87
• 20 Fang B, Yi C, Zhang H, Zhang Q, Li Y, Wei Q. et al. Combined epiphyseal preservation and autograft bone transfer in treatment of children osteosarcoma. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2013; 27: 45-9
• 21 Ruggieri P, Mavrogenis AF, Pala E, Romantini M, Manfrini M, Mercuri M. Outcome of expandable prostheses in children. J Pediatr Orthop 2013; 33: 244-53
• 22 Agarwal M, Puri A, Anchan C, Shah M, Jambhekar N. Rotationplasty for bone tumors: Is there still a role?. Clin Orthop Relat Res 2007; 459: 76-81
• 23 Winkelmann WW. Type-B-IIIa hip rotationplasty: An alternative operation for the treatment of malignant tumors of the femur in early childhood. J Bone Joint Surg Am 2000; 82: 814-28
• 24 Rödl RW, Pohlmann U, Gosheger G, Lindner NJ, Winkelmann W. Rotationplasty - quality of life after 10 years in 22 patients. Acta Orthop Scand 2002; 73: 85-8
• 25 Ogilvie CM, Crawford EA, Hosalkar HS, King JJ, Lackman RD. Long-term results for limb salvage with osteoarticular allograft reconstruction. Clin Orthop Relat Res 2009; 467: 2685-90
• 26 Bach AD, Kopp J, Stark GB, Horch RE. The versatility of the free osteocutaneous fibula flap in the reconstruction of extremities after sarcoma resection. World J Surg Oncol 2004; 2: 22
• 27 Beris AE, Lykissas MG, Korompilias AV, Vekris MD, Mitsionis GI, Malizos KN. et al. Vascularized fibula transfer for lower limb reconstruction. Microsurgery 2011; 31: 205-11
• 28 Dick HM, Strauch RJ. Infection of massive bone allografts. Clin Orthop Relat Res 1994; 306: 46-53
• 29 Abed YY, Beltrami G, Campanacci DA, Innocenti M, Scoccianti G, Capanna R. Biological reconstruction after resection of bone tumours around the knee: Long-term follow-up. J Bone Joint Surg Br 2009; 91: 1366-72
• 30 Innocenti M, Abed YY, Beltrami G, Delcroix L, Manfrini M, Capanna R. Biological reconstruction after resection of bone tumors of the proximal tibia using allograft shell and intramedullary free vascularized fibular graft: Long-term results. Microsurgery 2009; 29: 361-72
• 31 Erler K, Yildiz C, Baykal B, Atesalp AS, Ozdemir MT, Basbozkurt M. Reconstruction of defects following bone tumor resections by distraction osteogenesis. Arch Orthop Trauma Surg 2005; 125: 177-83
• 32 Puri A, Gulia A, Jambhekar N, Laskar S. The outcome of the treatment of diaphyseal primary bone sarcoma by resection, irradiation and re-implantation of the host bone: Extracorporeal irradiation as an option for reconstruction in diaphyseal bone sarcomas. J Bone Joint Surg Br 2012; 94: 982-8
• 33 Puri A, Subin BS, Agarwal MG. Fibular centralisation for the reconstruction of defects of the tibial diaphysis and distal metaphysis after excision of bone tumours. J Bone Joint Surg Br 2009; 91: 234-9
• 34 Puri A, Gulia A, Agarwal MG, Reddy K. Ulnar translocation after excision of a Campanacci grade-3 giant-cell tumour of the distal radius: An effective method of reconstruction. J Bone Joint Surg Br 2010; 92: 875-9
• 35 Chotel F, Nguiabanda L, Braillon P, Kohler R, Bérard J, Abelin-Genevois K. Induced membrane technique for reconstruction after bone tumor resection in children: A preliminary study. Orthop Traumatol Surg Res 2012; 98: 301-8
• 36 Pant R, Younge D. Turn-up bone flap for lengthening the below-knee amputation stump. J Bone Joint Surg Br 2003; 85: 171-3
• 37 Gosheger G, Hillmann A, Rödl R, Ozaki T, Gebert C, Winkelmann W. Stump lengthening after hip disarticulation using a modular endoprosthesis in 5 patients. Acta Orthop Scand 2001; 72: 533-6
• 38 Mohler DG, Kessler JI, Earp BE. Augmented amputations of the lower extremity. Clin Orthop Relat Res 2000; 371: 183-97
• 39 Ver Halen JP, Yu P, Skoracki RJ, Chang DW. Reconstruction of massive oncologic defects using free fillet flaps. Plast Reconstr Surg 2010; 125: 913-22
• 40 Pendegrass CJ, Gordon D, Middleton CA, Sun SN, Blunn GW. Sealing the skin barrier around transcutaneous implants: In vitro study of keratinocyte proliferation and adhesion in response to surface modifications of titanium alloy. J Bone Joint Surg Br 2008; 90: 114-21
• 41 Puri A, Gulia A. Management of extremity soft tissue sarcomas. Indian J Orthop 2011; 45: 301-6
• 42 Schwartz A, Rebecca A, Smith A, Casey W, Ashman J, Gunderson L. et al. Risk factors for significant wound complications following wide resection of extremity soft tissue sarcomas. Clin Orthop Relat Res 2013; 471: 3612-7
• 43 Marré D, Buendía J, Hontanilla B. Complications following reconstruction of soft-tissue sarcoma: Importance of early participation of the plastic surgeon. Ann Plast Surg 2012; 69: 73-8
• 44 Deneve JL, Turaga KK, Marzban SS, Puleo CA, Sarnaik AA, Gonzalez RJ. et al. Single-institution outcome experience using AlloDerm ® as temporary coverage or definitive reconstruction for cutaneous and soft tissue malignancy defects. Am Surg 2013; 79: 476-82
• 45 Senchenkov A, Petty PM, Knoetgen 3 rd J, Moran SL, Johnson CH, Clay RP. Outcomes of skin graft reconstructions with the use of Vacuum Assisted Closure (VAC(R)) dressing for irradiated extremity sarcoma defects. World J Surg Oncol 2007; 5: 138
• 46 Sakellariou VI, Mavrogenis AF, Papagelopoulos PJ. Negative-pressure wound therapy for musculoskeletal tumor surgery. Adv Skin Wound Care 2011; 24: 25-30
• 47 Muramatsu K, Ihara K, Doi K, Yoshida K, Iwanaga R, Hashimoto T. et al. Functional neuro-vascularized muscle transfer for oncological reconstruction of extremity sarcoma. Surg Oncol 2012; 21: 263-8
• 48 Grinsell D, Di Bella C, Choong PF. Functional reconstruction of sarcoma defects utilising innervated free flaps. Sarcoma 2012; 2012: 315190
• 49 Patel NV, Pedersen JC. Robotic harvest of the rectus abdominis muscle: A preclinical investigation and case report. J Reconstr Microsurg 2012; 28: 477-80
• 50 Komorowska-Timek E, Gurtner G, Lee GK. Supercharged reverse pedicle anterolateral thigh flap in reconstruction of a massive defect: A case report. Microsurgery 2010; 30: 397-400
• 51 Gordley K, Marco R, Klebuc M. Supercharged internal hemipelvectomy that enhances flap perfusion and decreases wound-healing complications. Orthopedics 2008; 31: 12
• 52 Townley WA, Mah E, O′Neill AC, Wunder JS, Ferguson PC, Zhong T. et al. Reconstruction of sarcoma defects following pre-operative radiation: Free tissue transfer is safe and reliable. J Plast Reconstr Aesthet Surg 2013; 66: 1575-9
• 53 Chao AH, Chang DW, Shuaib SW, Hanasono MM. The effect of neoadjuvant versus adjuvant irradiation on microvascular free flap reconstruction in sarcoma patients. Plast Reconstr Surg 2012; 129: 675-82
• 54 Ghert MA, Davis AM, Griffin AM, Alyami AH, White L, Kandel RA. et al. The surgical and functional outcome of limb-salvage surgery with vascular reconstruction for soft tissue sarcoma of the extremity. Ann Surg Oncol 2005; 12: 1102-10
• 55 Muramatsu K, Ihara K, Miyoshi T, Yoshida K, Taguchi T. Clinical outcome of limb-salvage surgery after wide resection of sarcoma and femoral vessel reconstruction. Ann Vasc Surg 2011; 25: 1070-7
• 56 Deune EG, Rodriguez E, Hatef D, Frassica F. Arterialized venous flow-through flap for simultaneous reconstruction of a radial artery defect and palmar forearm soft-tissue loss from sarcoma resection. J Reconstr Microsurg 2005; 21: 85-91
• 57 Garvey PB, Clemens MW, Rhines LD, Sacks JM. Vertical rectus abdominis musculocutaneous flow-through flap to a free fibula flap for total sacrectomy reconstruction. Microsurgery 2013; 33: 32-8
• 58 Renard AJ, Veth RP, Schreuder HW, van Loon CJ, Koops HS, van Horn JR. Function and complications after ablative and limb-salvage therapy in lower extremity sarcoma of bone. J Surg Oncol 2000; 73: 198-205