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.

Keywords: Bone tumor; reconstruction; sarcoma.

Figure 1

A case of malignant bone tumour of the humerus with an intramedullary implant in situ. Treated with wide excision and reconstructed with a total humerus prosthesis

Figure 2

Immediate postoperative radiograph of an expandable prosthesis (left). The same prosthesis after serial expansion in vivo (right). The double headed arrow demonstrates the region of expansion

Figure 3

Pictorial representation of rotationplasty depicting excision of a lower end femur tumor followed by rotation and shortening of the distal limb. The image on the right shows the eventual clinical outcome with the prosthesis that is used

Figure 4

Preoperative and follow-up radiograph at 24 months of a diaphyseal osteosarcoma of the radius; excised and reconstructed with a vascularised fibula (arrows demonstrate the united osteotomy junctions)

Figure 5

(a) Preoperative radiograph of a diaphyseal osteosarcoma of the femur, (b) follow-up radiograph at 24 months after excision and reconstruction with a combination of vascularised fibula and allograft

Figure 6

Combination of vascularised fibula and allograft (black arrow) used for reconstruction as shown in Figure 5

Figure 7

(a) Preoperative magnetic resonance imaging of a Ewing sarcoma of the tibia, (b) follow-up radiograph at 36 months showing hypertrophy of the transposed (medial translation into post excision defect) fibula

Figure 8

Recurrent synovial sarcoma of the leg. Treated with wide excision and the defect covered with a free antero lat thigh flap