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Principles of
Surgery
BY:
Dr Majdi S Qutob
EDITORS:
Dr Michelle Ghert
Dr Nigel Colterjohn
Outline
1. Amputation vs.Limb Salvage (When in doubt, cut it out???)
2.Margins (What is it and why should we care?)
3.Curettage Resection
4. Reconstruction
Questions when addressing Amputation vs. Limb salvage
1. How do the short‐term and long‐
term morbidity compare?
2.Will survival be affected by the treatment?
3.How will the function of the salvaged limb compare to that of a prosthesis?
4. Are there any psychosocial consequences?
Amputation
Definition
“The removal of a body extremity by trauma
or surgery.”
Benefits
• Technically less complicated
• Fewer complications.
• No further surgery (revisions)
• Faster return to function
• Better overall function
• Advanced artificial limbs design
Amputation
• Technically demanding (non-standard flaps,
or bone augmentation)
Complications
• Infection
• Wound dehiscence
• Chronic painful limb
• Phantom limb pain
• Appositional bone overgrowth requiring
revision
Limb Salvage
• Definition
– A surgical process for the purpose of preventing limb loss, and ideally achieving wound healing and resolution of disease process
– Limb Sparing
• Benefits
– Maintains bone stock
– Psychological
– Advancement of surgical options
– Increased functionality
Amputation vs Limb salvage
• Advancements that allow for
Limb Salvage:
–
–
–
–
–
Diagnostic imaging
Chemotherapy
Radiation therapy
Surgical technique
Preoperative radiation Tx for soft
tissue sarcomas
– Neoadjuvant chemotherapy for
bone sarcomas
Limb Salvage
Complications
• Increased perioperative and long‐term morbidity
• Extensive surgery
• Risk of infection
• Wound dehiscence
• Flap necrosis
• Blood loss
• DVT
Limb Salvage
Long term complications
• Periprosthetic fractures • Prosthetic loosening or dislocation
• Non‐union graft‐host junction
• Allograft fracture
• Leg length discrepancy
• Late infection
Surgical Margins
1.
2.
3.
4.
Intralesional Marginal Wide
Radical
Defined for both Amputations and Limb Sparing Resections
Eight Different Surgical Procedures Overall Enneking Classification for Limb Salvage
Enneking Classification for Amputations
Intralesional Margin
• “Debulking”
• Plane of dissection is within the tumor
• Leaves gross tumor
• Appropriate for symptomatic benign lesions when the only surgical alternative would be to sacrifice important anatomical structures
Marginal Margin
• Closest plane of dissection is through the pseudo‐capsule • Pseudo‐capsule surrounding reactive tissue (satellite lesions)
• Most benign lesions and some low‐grade malignancies
• Local recurrence????
Wide margins • Plane of dissection is in normal tissue
• Entire tumour surrounded by cuff normal tissue
• Procedure of choice for high grade malignancy Radical margins • All the compartments that contain tumour is resected
• Once procedure of choice for high‐grade neoplasm • Now rare
• Wide now procedure of choice for High Grade Neoplasm
Limb Sparing
Amputation
Resection
• GOAL‐ Wide surgical margins!!!!!
• If cannot achieve wide surgical margins (2cm) combined with adjuvant and neoadjuvant Tx
Curettage
• Use of a curette to remove tissue by scraping or scooping
• Higher rate of local recurrence
Principles of “Simple” Curettage
1.
2.
3.
4.
Large cortical window over the lesion
Bulk of tumour is scooped out with curettes
Cavity is enlarged with a high‐speed burr
Copious Irrigation with water (cell lysis)
“Extended” Curettage
• Use of Adjuvants (liquid nitrogen, phenol, PMMA (Polymethylmethacrylate), ultrasound or thermal cautery)
• Cryotherapy‐ kill zone 14mm superior to phenol and methacrylate
• 5% Phenol ‐ kill zone 2‐3mm
• PMMA Bone Cement‐heat and direct toxicity and filling agent
Defect Remodeling
Defect Filling Options
1. Autogenous Bone –most reliable healing but increased morbidity
2. Cancellous Allograft ‐high healing rate; large amounts; risk of infection???
3. BG Substitute –relatively cheap; easy to use; available
4. Bone Cement ‐immediate stability; increased detection of tumor recurrence
5. Nothing
Reconstruction
Four options:
1. Osteoarticular Allograft/Autograft
2. Endoprosthetic
3. Allograft‐Prosthesis Composite
4. Rotationplasty
Osteoarticular Allograft/Autograft
• Definition: A section of auto/allograft bone with overlying cartilage used to replace the affected bone. • Advantages: – Replace ligaments, tendons and intra‐articular structures
– Preserves bone stock
• Complications: –
–
–
–
Non‐union
Fatigue fractures
Articular collapse, dislocation, degenerative joint disease
Failure of ligament/tendon attachments
Osteoarticular Autograft
Endoprosthesis
• Definition: An artificial replacement of a body part that is placed internally.
• Advantages: – Long‐term solutions
– Immediate stability quicker rehab and full weight‐
bearing
– Modular for incremental lengthening for immature pt grows
• Complications: – Polyethylene wear
– Fatigue fractures
– Infection
Endoprosthesis
Allograft‐Prosthesis Composite
• Definition: A hybrid of artificial and biological replacement of a body part that is placed internally.
• Advantages: – Long‐term solutions
– Avoid degenerative joint disease articular collapse
– Preserving soft tissue structures
• Complications: –
–
–
–
–
Fatigue fracture
Infection
Non‐union
Technically demanding Inadequate host bone interface
Allograft‐Prosthesis Composite
Rotationplasty
• Resection of pathological bone and soft tissue (sarcoma)
– Distal femur/proximal tibia
– Intercalary amputation
• Rotation of the residual limb 180 deg
• Attachment of bones together
• Neurovascular remains untouched
• The remaining ankle becomes the knee: Gastrocs to sartorius/rectus femoris ‐Tibialis
anterior to hamstrings
Advantages:
Rotationplasty
• More efficient
• More physiological gait than alternative
• Avoid phantom limb pain
• Psychological implications
•Intercalary amputation and
reimplantation
• Preserves nerve supply
• Removes tumor
• Preserves movement and power
Summary
1. Amputation vs. Limb salvage
2. Surgical Margins (Intralesional, Marginal, Wide, Radical)
3. Curettage with Defect Filling Options
4. Reconstruction Options (Osteoarticular Allo/Autograft, Endoprosthesis, Allograft‐
prosthesis composite, Rotationplasty)
When in doubt ask for help!!!!
Questions????