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Chapter 2E - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

The Choice Between Limb Salvage and Amputation: Tumor

Walid Mnaymneh, M.D. 

Limb salvage surgery is any procedure that effectively removes a bone or soft-tissue tumor while preserving the limb with a satisfactory functional and cosmetic result. For many years amputation was the conventional surgical treatment of malignant bone and soft-tissue tumors. However, since the midseven-ties and as a result of advances in adjuvant chemotherapy and radiotherapy newer staging studies of tumors, and improved surgical techniques of skeletal and soft-tissue reconstruction, there has been an upsurge of interest in limb-saving procedures in lieu of amputation. Moreover, limb-saving procedures have proved to be as effective as amputation in terms of local tumor control without compromising survival.

The treatment plan for malignant tumors is a mul-tidisciplinary one utilizing surgery, chemotherapy, and radiotherapy as well as the supportive services of psychologists, prosthetists, physical therapists, and social workers. It is based mainly on the surgical stage of the tumor as well as its size and anatomic location. The surgical stage of the tumor is based on its histogenic type (as determined by biopsy) as well as on its local extent and any existing metastasis^8-11 (as determined by radiologic studies including radiographs, bone scan, computed tomography [CT], and magnetic resonance imaging [MRI]).

The biopsy is done after completion of the radiologic staging studies and should be carried out by the surgeon who will perform the definitive surgery. A poor biopsy technique may have a profound adverse effect on the subsequent definitive surgical treatment and in fact may preclude the execution of an otherwise feasible limb-saving procedure. The biopsy incision should be longitudinal rather than transverse and should be correctly placed in line with the planned incision of the subsequent surgery so that in case a limb-saving procedure is done, the biopsy tract can be excised in continuity with the resected tumor. Deeper dissection should avoid intermuscular planes and should stay clear of the major neurovascular structures. Intraosseous biopsy material is obtained through a round or oval cortical window. Plugging the intraosseous biopsy site with methylmethacrylate cement may be done to prevent soft-tissue spread of the tumor hematoma. A frozen-section tissue preparation for immediate appraisal of the adequacy of the specimen for diagnosis is recommended. In a multicenter study, Mankin et al. reported an almost 20% incidence of significant problems in patient management caused by inappropriate biopsy technique. It was found that 8% of the biopsy procedures produced significant adverse effect on prognosis and that 4.5% of the patients who might have had a limb-saving procedure required an amputation as a result of an ill-planned biopsy. Moreover, errors in diagnosis occurred twice as commonly when the biopsy was done in a community hospital as opposed to when it was done in an oncologic center. Hence, it is recommended that patients be transferred to a specialty center before rather than after the biopsy.

The new staging system that has been adopted by the Musculoskeletal Tumor Society^8-11 and that is currently utilized by most orthopaedic oncologic surgeons applies to bone as well as soft-tissue tumors. It categorizes benign tumors into three stages designated by Arabic numerals: stage 1 (latent), stage 2 (active), and stage 3 (aggressive). Malignant tumors are categorized into three stages designated by Roman numerals: stage I (low-grade malignancy without metastasis), stage II (high-grade malignancy without metastasis), and Stage III (any malignant grade with regional or distant metastasis). Both stage I and stage II are subdivided into A (intracompartmental) and B (extracompartmental).

Treatment strategy following the staging of the tumor is dependent on the tumor characteristics: in the case of high-grade, chemotherapy-sensitive bone tumors such as osteosarcoma and Ewing's sarcoma, treatment is initiated with neoadjuvant preoperative chemotherapy; no such therapy is given in low-grade bone tumors including chondrosarcoma. A similar strategy is followed in soft-tissue tumors: high-grade soft-tissue sarcomas are treated preoperatively with either chemotherapy or radiotherapy, or both, whereas low-grade soft-tissue sarcomas are not. Definitive surgical treatment is then performed and consists of resection with limb saving, if feasible, or amputation. Histologic assessment of the extent of necrosis in the resected primary tumor allows an evaluation of the efficacy of the preoperative chemotherapy and hence will help in selecting the appropriate adjuvant postoperative chemotherapy. An additional advantage of preoperative chemotherapy is the possible reduction of tumor size. Sometimes there is sufficient reduction in tumor size to change an equivocal limb-saving situation into a definitely feasible one. Moreover, the chemotherapy-induced necrosis could conceivably reduce the potential escape of viable tumor cells during the operation. Postoperatively, chemotherapy, radiotherapy, or both are usually administered, depending on the type of tumor and the surgical procedure performed.

SURGICAL TREATMENT

In the decision-making process of choosing between amputation or limb salvage procedure, the ultimate goal of treatment should be to maximize the patient's survival and minimize the risks of metastasis and local recurrence. Other important factors to be considered include the psychological impact of the surgical treatment in terms of the resultant body image and quality of life as well as the function of the operated limb. Recently, there have been serious efforts to examine the true merits of limb-saving procedures over amputations. Interestingly, a few studies have actually shown no significant difference in the psychological and quality-of-life parameters between patients with limb-saving and amputation procedures. A study specifically targeting tumors about the knee showed no significant difference in psychological and physical function,whereas another study showed that patients whose limbs were salvaged by knee arthroplasty walked at a higher velocity and with a lower net energy cost than did patients who had above-knee (transfemoral) amputation. Obviously, further similar comparative studies that are stratified by the level of amputation and that utilize more sensitive tests are needed to reach a rational scientific answer to the important question of whether patients and their treating physicians prefer limb-saving procedures because of preconceived notions of the resultant body image and quality of life or because of conclusive measurable subjective and objective advantages of limb-saving procedures. The author strongly believes that such procedures are superior to high amputations around the hip and shoulder where not only body image and function are severely affected but also because a normal limb distal to the tumor site is unnecessarily sacrificed.

This chapter describes the limb-saving procedures only. Amputations are discussed in another chapter.

INDICATIONS FOR LIMB-SAVING PROCEDURES

Conceptually, limb-saving procedures are indicated if all the following criteria are deemed attainable:

1. An oncologically sound wide or radical resection of the tumor can be achieved.
2. Limb reconstruction is technically feasible.
3. The prognosis, in terms of survival and local recurrence, is not compromised.
4. The cosmetic and functional results are superior to those of an amputation, with due consideration given to the patient's life-style, needs, and demands. The ultimate goal is not merely "salvaging" the limb but reconstructing a functional and cosmetically appealing limb.

By and large, if one or more of these criteria are considered unattainable, amputation becomes the preferred option.

Tumors that lend themselves to limb-saving procedures include malignant tumors (stage I and II) and some recurrent aggressive benign tumors (stage 3). Obviously, early diagnosis is important for successful limb saving inasmuch as a delay in diagnosis allows the tumor to increase in size, thus making limb saving less feasible.

In general, limb salvage procedures are technically more complex than amputations. In bone tumors, it comprises two procedures: tumor resection and skeletal reconstruction. In soft-tissue tumors, soft-tissue reconstruction is rarely needed.

TUMOR RESECTION

In both bone and soft-tissue tumors, resection should be performed according to strict surgical oncologic principles. The recommended procedure for malignant tumors is either radical or, more frequently, wide resection of the tumor. In bone, radical resection indicates removing the entire bone from joint to joint, whereas wide resection indicates removing the tumor with a wide margin of normal bone around it. In soft tissue, radical resection indicates removing the entire muscle compartment from origin to insertion, whereas wide resection indicates removing the tumor with a wide surrounding cuff of normal soft tissues in all dimensions (Fig 2E-1,A-C). At the present time, most orthopaedic oncologists perform wide resection of the tumor combined with chemotherapy and radiotherapy. The adequacy of the resection cannot be overemphasized inasmuch as inadequate resection is the main cause of local recurrence, which in turn implies a worse prognosis. Optimal resection should not be compromised for the sake of subsequent reconstruction. The resectability of the tumor, based on its intraosseous and extraosseous extent, is preoperatively determined by radiologic staging studies, especially MRI and CT studies. Previous biopsy scars and tracts are excised in continuity with the tumor. The level of bone resection should include a margin of normal bone ranging from 3 to 5 cm beyond the tumor limit. For epiphyseal or metaphyseal tumors, an intra-articular resection including the articular surface is performed. If there is evidence of tumor extension into the joint, an extra-articular resection including the whole joint is indicated. An adequate surrounding cuff of soft tissues around the bone is also resected. Displacement or even involvement of adjacent neurovascular structures are not absolute contraindications to resection, i.e., indications for amputation. If a major indispensable vessel is displaced but not directly involved by the tumor, a careful subadventitial dissection is performed to preserve the vessel. Under proper circumstances, a vessel directly involved by tumor or circumferentially surrounded by tumor can be sacrificed and replaced by a vein graft or a synthetic graft. If necessary, resection of invaded major nerves may be performed. Resultant functional deficit is rectified by means of external orthoses or by reconstructive surgery.

Adequacy of margins of excision is documented by frozen-section microscopic examination of sampled tissues intraoperatively.

SKELETAL RECONSTRUCTION

Postresection skeletal reconstruction constitutes the second stage of the operative procedure. The need and the type of reconstruction are determined preoperatively. In cases where dispensable or so called "nonessential" bones are resected, no reconstruction is needed to preserve function. The scapula (except the glenoid portion), clavicle, rib, proximal part of the radius, distal end of the ulna, metacarpal, phalanx, ischium, pubis, patella, fibula (except the distal end), and metatarsal bone can be resected with compensable disturbance of function. However, in nondispensable or "essential" bones, skeletal reconstruction is indicated to preserve the limb and its function. The choice of the reconstructive procedure is contingent on the location of the tumor, the size of the resected bone, the patient's lifestyle, and the surgeon's preference and expertise. There are three major methods of skeletal reconstruction: (1) intercalary (segmental) reconstruction, (2) arthrodesis, and (3) arthroplasty. By and large, the commonly used skeletal substitutes in these reconstructive methods include autografts, allografts, and metallic prostheses.

Intercalary reconstruction is needed after diaphyseal resection, and it utilizes allografts, autografts, or rarely, metallic prostheses.

Arthrodesis is used to reconstruct the limb after extra-articular resection of a joint such as the knee, shoulder, or wrist. It also utilizes allografts, autografts, or rarely, metallic prostheses.

Arthroplasty is used to replace a resected hemijoint or whole joint with an articulating joint such as the knee, hip, shoulder, elbow, or wrist. It utilizes allografts, customized metallic prostheses, or allograft-prosthesis composites.

Autografts are the best bone substitutes. However, these are not commonly used because they cannot replace large bone segments and articular joint surfaces cannot be provided. Nevertheless, two useful surgical techniques utilizing large autografts can be used in selected cases. One is resection-arthrodesis of the knee. Following wide resection of the proximal third of the tibia or distal part of the femur, arthrodesis of the knee is achieved by inserting a long intramedullary nail and bridging the resection defect with a combined construct made up of the ipsilateral fibula and a half of the proximal end of the tibia (to replace a resected distal femur) or half of the distal part of the femur (to replace a resected proximal tibia). When successful, this technique produces a long-lasting and durable reconstruction. However, most patients prefer to have a movable rather than a fused knee. The other surgical technique is the use of a vascularized free fibular autograft as an intercalary graft to reconstruct a diaphyseal defect. Unlike an avascular fibular allograft, the healing potential is greatly improved, being similar to fracture healing. The graft is more readily incorporated and frequently hypertrophies with time.

In contrast to autografts, both allografts and prostheses can replace large segments of bones and provide movable joints. Conceptually, allografts have certain advantages over prostheses. These are related to the biological nature of the allograft, which allows healing at the graft-host junction by a process of creeping substitution, and the presence of allograft stubs of tendons and ligaments, which serve as anchors to which host tendons and ligaments can be reattached, thus restoring motor function and joint stabilization. Conversely, metallic prostheses have the potential late complications of loosening or fatigue fracture of the prosthesis, especially in younger patients with high physical activity levels. Moreover, an osteoarticular allograft replaces only the involved half (or quarter) of the joint, thus sparing the uninvolved normal portions of the joint, whereas a joint prosthesis necessitates the sacrifice of the normal uninvolved half of the joint in order to accommodate the prosthesis. On the other hand, the advantages of prostheses include a simple operative procedure, quicker recovery, and easier rehabilitation, in contrast to the long rehabilitation following allografting procedures.

Although we generally favor allografts, we prefer to use metal prostheses in conjunction with intercalary allografts (allograft-prosthesis composite) in lieu of os-teoarticular allografts to replace the proximal part of the femur and the proximal end of the humerus because, in our experience, there has been an unacceptably high incidence of fragmentation and collapse of the allograft femoral and humeral head. Prostheses are also recommended in patients with metastatic tumors.

To help solve some of the problems encountered with customized prostheses, in terms of fracture, loosening, need for customized implants, improper size, and high cost, new modular segmental defect replacement prostheses have recently been developed for the proximal and distal ends of the femur and proximal parts of the tibia and humerus. This system depends on a dual fixation concept, with initial fixation of the solid intramedullary stem by methylmethacrylate bone cement and long-term fixation by extracortical bone bridging and ingrowth over the porous shoulder region of the segmental prosthesis. The bone bridging around the prosthesis is accomplished by applying autogenous iliac grafts over the porous segment. Initial clinical results seem to be quite promising.

Useful new "expandable" metallic prostheses have been successfully used in children with malignant tumors of long bones of the limbs. Previously, limb saving in young children was not recommended when epiphyseal growth plates of long bones had to be sacrificed with the resected tumor because of the expected significant shortening of the limb. These expandable prostheses allow periodic lengthening of the devices to gradually keep up with the growth of the contralateral limb (Fig 2E-2,A-D).

ALLOGRAFT PROCEDURES

We have used four types of allografting procedures to reconstruct large skeletal defects in bone tumors. These are massive osteoarticular allografts, allograft-prosthesis composites, intercalary allografts, and intercalary allograft-arthrodesis. The indication for each of these procedures is dictated by the skeletal location and extent of tumor resection. Osteoarticular allografts are glycerol-treated frozen allografts and are the most commonly used. They are usually utilized as hemijoints to reconstruct the knee, wrist, shoulder, and elbow joints. Whole-joint allografts have proved unsatisfactory because of articular cartilage degeneration and bone fragmentation reminiscent of Charcot (neuropathic) joints. Intercalary allografts are either frozen or freeze-dried and are used to reconstruct diaphyseal defects, to achieve arthrodesis following knee or shoulder joint resection, or as allograft-prosthesis composites to reconstruct the hip or shoulder joints.

An allografting procedure is often complex and lengthy, being a two-in-one procedure combining resection and reconstruction. To achieve optimal results, particularly in the osteoarticular allograft, certain technical aspects have to be heeded. These include size matching of the graft to the resected segment; rigid fixation of the graft-host junction; congruent joint fit; reconstruction of ligaments, tendons, and joint capsule; and adequate skin and soft-tissue coverage by utilizing, if necessary, local muscle transfer, skin grafts, or free flaps.

The following are examples of allograft reconstruction of the limbs:

Scapula

The whole scapula or the functionally important glenoid and neck portion can be replaced by a scapular allograft.

Humerus

The proximal or distal thirds of the humerus can be successfully replaced by an osteoarticular allograft. However, we have observed a relatively high incidence of late fracture or fragmentation of the humeral head (Fig 2E-3,A-C). This has not been a problem with distal humeral allografts. Accordingly, we now recommend using an allograft-prosthesis composite to replace the proximal end of the humerus by utilizing a long-stem Neer endoprosthesis combined with an intercalary humerus allograft. When evaluation necessitates resection of the whole glenohumeral joint or resection of the deltoid muscle and rotator cuff, then we recommend an allograft-arthrodesis utilizing a proximal humerus allograft with fusion to the scapula (Fig 2E-4,A-B).

Radius

The distal end of the radius can be replaced by a size-matched osteoarticular allograft that is fixed to the host radius by a dorsally placed compression plate (Fig 2E-5,A and B). We have observed a late complication of volar subluxation of the carpus on the allograft radius with progressive degenerative changes in the radiocarpal articulation. To prevent this complication we now recommend the use of the donor's contralateral radius with a 180-degree rotation on its longitudinal axis. Theoretically, by rotating the allograft, the normally long dorsal lip of the articular surface of the radius becomes volar, thus acting as a blocking strut against volar subluxation of the carpus.

Pelvis

In selected patients with tumors of the bony pelvis, a partial or complete internal hemipelvectomy can be as effective as a conventional transpelvic amputation. However, this procedure produces significant disability in terms of loss of hip function and stability. We favor the use of a massive pelvic osteoarticular allograft to replace the resected hemipelvis. When successful, the pelvis allograft restores anatomy, stability, function, and leg length. (Fig 2E-6,A and B). In case the femoral head and neck have to be included in the resection, then a bipolar femoral prosthesis is used rather than a proximal femoral allograft.

Femur

In the proximal end of the femur, we favor the use of a proximal femoral allograft combined with a long-stem femoral prosthesis instead of an osteoarticular allograft (Fig 2E-7,A and B). This allograft-prosthesis composite provides a strong construct as well as a good osseous bed for reattaching tendons, particularly the hip abductors, either by directly suturing the tendons to the allograft trochanter or by fixing the patient's greater trochanter to the allograft. Diaphyseal defects are reconstructed by an intercalary allograft (Fig 2E-8, A-C).

In the distal third of the femur, osteoarticular allografts have been successful in our hands. The whole distal part of the femur (Fig 2E-9,A-C) or one femoral condyle can be replaced. To restore joint stability and function, size matching of the allograft and joint fit as well as ligamentous repair are critical. The stubs of the allograft collateral and cruciate ligaments are sutured to the corresponding stubs of the patient. If such stubs are absent, we have reconstructed the ligaments by utilizing a hemi-Achilles tendon allograft.

When the whole knee joint has to be resected, we have successfully used distal femur and proximal tibia allograft-prosthesis composites and incorporated a rotating hinged-knee prosthesis.

Tibia

Proximal tibial osteoarticular allografts have been used successfully (Fig 2E-10,A and B). Ligament reconstruction of the joint is similar to that used with the distal femoral allograft.

POSTOPERATIVE MANAGEMENT

Because of the increased potential risk of infection, antibiotic treatment is continued postoperatively for about 3 months.

In proximal femur allograft-prosthesis composites, the patient walks by utilizing an abduction hip brace and crutches for 2 to 3 months, folowed by a crutch or a cane.

In allografts in the knee region, we immobilize the limb in a long-leg plaster cast for 8 weeks to allow soft-tissue and ligament healing. This is followed by protection of the limb in a knee-ankle-foot orthosis and gradual mobilization of the knee joint. The orthosis is kept until there is radiologic evidence of union at the al-lograft-host junction. Of course, the patient uses crutches to avoid weight bearing on the affected leg until union occurs.

In proximal humerus allografts, a shoulder abduction splint is used for about 6 weeks, followed by protection in a sling and gradual mobilization of the shoulder joint. In distal radius allografts, the forearm is immobilized in a short-arm plaster cast, followed by protection in a volar splint and gradual mobilization of the wrist joint.

CLINICAL RESULTS

These limb-saving resection-reconstructive procedures utilizing massive allografts are often complex and long procedures with relatively high rates of complications. At the University of Miami, our 2- to 11-year follow-up retrospective evaluation of the massive osteoarticular allografts, which technically are the most complex and challenging, has shown the following results. According to Mankin's grading system, our results are 61% good or excellent, 13% fair, and 26% failure. The allograft-related complications consisted of 10% infection, 7% nonunion of the graft-host junction, 20% fracture of the allograft, and 5% resorption of a portion of the allograft (such as the humeral head). However, over half of these complications were salvaged by subsequent surgery such as autografting a fractured or nonunited allograft, replacing a fractured allograft with a new allograft, or replacing a resorbed humeral head with a Neer shoulder endoprosthesis. It is our firm impression that the learning experience with these allografting surgical techniques has enabled us to reduce the incidence of our earlier complications.

In view of the biological advantages, availability, and versatility of allografts and despite the potential complications, the use of these allografts (either alone or in combination with metal prostheses) provides a useful reconstructive method in limb salvage procedures following wide resections of bone tumors.

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Chapter 2E - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

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