WELCOME LECTURE

dr. Rizki Rahmadian

 mimpi adalah kunci untuk kita

menaklukan dunia, berlarilah
tanpa lelah sampai engkau
meraihnya
nidji

Limb Salvage Surgery for

Extremity Bone Sarcoma

Amputation

Introduction
Concept of limb salvage surgery 25 years
1970s adriamicyn & MTX
Ralp Marcove, Kenneth Francis & Hugh Watts
limb salvage surgery technique

Introduction

Today 90-95 % patient with extremity sarcoma

who are treated at major centers specializing in
musculoskeletal oncology can undergo limbsparing surgery procedures

Introduction
This dramatic alteration :
1. Improved understanding of tumor biology;
2. Effective induction chemotherapy;
3. Technical advances in surgical techniques;
4. Better characterization of the biomechanics of the human
skeleton;
5. Advanced material engineering and manufacturing
techniques;
6. The development of a reliable, stable modular prosthesis
for reconstruction of the hip, shoulder, and knee.

Early Management & Referral

A successful limb salvage depends on :
A well - coordinated and timely series the
first physician to see the patient
History and general examination
The basic work-up should include high quality
plain radiographs for bone lesions.

Early Management & Referral

Biopsy is not a part of the initial management of

these lesions and is usually the last step in the
work-up.
The biopsy should be performed by the
surgeon who will be doing the definitive
surgery.

Work-up
Multidisciplinary team :
Orthopedic oncologist
Medical oncologist
Radiation oncologists
Musculoskeletal radiologist
Pathologist
Clinical psychologist
Social worker

CLINICO PATHOLOGICAL CONFRENCE

Staging
The basic staging work :
High quality plain radiographs
Magnetic resonance imaging
study of the entire tumor and
nearby anatomic structures
Computed tomography scan of the
chest
Whole body technetium bone scan
Biopsy of the tumor

Work-up
The biopsy site must be carefully
planned and located along so-called
limbsalvage lines

Biopsy

Drain Placement

Staging

Patient Education
The patient and the patients family
should be given the opportunity to
participate in the decision

Indication
Every patient with a malignant tumor of the
extremity should be considered for limb salvage.
The patients prognosis has a limited impact on
the decision to perform limb salvage surgery.
In selected cases, limb salvage can be
combined with metastasectomy.

Indication
Minimum morbidity and rapid return to
function.
Patients can enjoy relief from pain,
improved quality of life, and intact body
image that limb salvage can offer, even if
they may not survive long-term.

Barriers
Barriers to limb salvage include
Poorly placed biopsy incisions,
Major vascular involvement,
Incasement of a major motor nerve,
Pathological fracture of the involved bone,
and others.
These adverse factors should not be viewed
as absolute contraindications.

STAGES OF LIMB-SPARING SURGERY

Limb-sparing procedure can be divided into five

stages :
Neoadjuvant chemtherapy
Tumor resection must spare significant
structures.
Stable, painless skeletal reconstruction
The surrounding and supporting soft tissue
Adjuvant chemotherapy

Huvos Tumor Necrosis Grading

System

Surgical Resections and

Reconstructions
The cornerstone of a limb
salvage procedure is a
complete resection of the
tumor with an adequate
margin.
Margins can be defined
as intralesional, marginal,
wide, and radical

Surgical Resections and

Reconstructions
After completion of the tumor resection, the
surgeon must reconstruct the resulting surgical
defect.
The excised segment of bone must be replaced

Large internal prosthesis,

Segment of allograft bone,
Composite of an allograft and a prosthesis
Other methods.

Resection Arthrodesis

Resection Arthrodesis

Osteoarticular Allograft

Endoprosthesis

Endoprosthesis

Expandeble endoprosthesis

Case

 Survival : 5 yaers survival rate 40 -70 %,

local recurrence : 5 -10 %
Immidiatete and Delayed Morbidity : increase revision
Function : better than amputation
Psycosocial Benefits : gooad early psycosocial adjustment

Thank you