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Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 43-45

Limb salvage for malignant bone tumors: Surgical audit in a case of osteogenic sarcoma

Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Date of Web Publication28-Dec-2018

Correspondence Address:
Prof. Alok C Agrawal
H-2, Sector 2, Agrasen Nagar, Raipura, Raipur, Chhattisgarh 492013
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.JODP_1_18

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Limb Salvage has become the state of Art treatment used in managing maligmant bone tumours. Many times with the ignorence of tumour behaviour and natural history, absence of protocols, peer pressure and growing confidence levels, some common principles are missed leading to poor outcome. This paper deals with a surgical audit of avoidable complications following limb Salvage in a case of osteogenic sarcoma.

Keywords: Limb salvage, osteogenic sarcoma, surgical audit

How to cite this article:
Agrawal AC. Limb salvage for malignant bone tumors: Surgical audit in a case of osteogenic sarcoma. J Orthop Dis Traumatol 2018;1:43-5

How to cite this URL:
Agrawal AC. Limb salvage for malignant bone tumors: Surgical audit in a case of osteogenic sarcoma. J Orthop Dis Traumatol [serial online] 2018 [cited 2019 Jan 23];1:43-5. Available from: http://www.jodt.org/text.asp?2018/1/1/43/248898

  Introduction Top

Limb salvage has become the state-of-the-art treatment used in managing malignant bone tumors. Neoadjuvant chemotherapy, surgery, and adjuvant radiotherapy/chemotherapy have improved patient survival from 10% to approximately 70% in malignant bone tumors.[1],[2]Long-term observations show that limb salvage operations, performed with wide margins along with chemotherapy, do not compromise the survival or local control in malignant bone tumors as compared to radical amputations. Hence, more and more malignant bone tumors are being treated by limb salvage. Many times with the ignorance of tumor behavior and natural history, absence of protocols, peer pressure, and growing confidence levels, some common principles are missed, leading to a poor outcome. This paper deals with a surgical audit of avoidable complications following limb salvage in a case of osteogenic sarcoma.

The surgical audit was carried out following limb salvage in a case of osteogenic sarcoma of the proximal tibia with poor results. The common causes of a poor outcome are delay in diagnosis and surgery, unavailability of recommended noninvasive imaging modalities, wrong biopsy, wrong timing in relation to neoadjuvant chemotherapy and chemotherapy, selection of a wrong method of reconstruction, wrong plane of dissection, and poverty, whereby the patient cannot follow instructions or come for a timely follow-up. The psychological state of the patient is also important in deciding the outcome. A pictorial case discussion planned for this case is as follows:

  Case Report Top

A young 14-year-old male patient with a mammoth high-grade extra-compartmental osteogenic sarcoma [Figure 1] without metastasis (Enneking’s Grade II B) of the right proximal tibia was treated as per protocol with limb salvage.[3] The patient was given an option of amputation as the tumor was very large and inoperable, but he did not accept it and so as per his desire, limb salvage surgery was performed by excision of the proximal tibia followed by reconstruction by a limb preservation system of proximal tibia and knee arthroplasty. Following surgery, the skin necrosis was treated with gastroc soleus flaps [Figure 2] and [Figure 3], and after 6 months, the patient returned with secondary local soft tissue recurrence [Figure 4].
Figure 1: Mammoth osteogenic sarcoma of proximal tibia

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Figure 2: Flap necrosis following surgery

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Figure 3: Gastrocnemius flap done to treat flap necrosis

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Figure 4: Late local soft tissue recurrence

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Audit: High-grade extra-compartmental osteogenic sarcomas without metastasis are treated in the method described with neoadjuvant chemotherapy, surgery, and adjuvant chemotherapy. No investigation can find micrometastasis or satellite lesions in the reactive zone and this is a major cause of soft tissue recurrence. In this case, who presented very late to us, local soft tissue infiltration cannot be ruled out. During surgery, it is imperative to use a gastrocnemius rotational flap to cover the prosthesis and avoid skin necrosis. Following surgery, the patient could not take adjuvant chemotherapy because of multifactorial factors, mainly lack of education and poverty, and he showed poor results over time. For us, he was lost to follow-up.

  Discussion Top

In India, there are only few centers of excellence for limb salvage in malignant bone tumors. Even if most centers have computed tomography and magnetic resonance imaging scanning, they will be lacking in radionuclide imaging and many times, the investigations will not be repeated because of the cost involved. In spite of preoperative counseling, the patients do not show up for follow-up and adjuvant chemotherapy following limb salvage, taking themselves to be cured, and many of the complications can be minimized by following a predefined protocol instead of a subjective assessment of the patient.[4]We recommend rigid protocols in place of individualistic opinions to avoid the majority of complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Meyers PA, Heller G, Healey J, Huvos A, Lane J, Marcove R, et al. Chemotherapy for nonmetastatic osteogenic sarcoma: The Memorial Sloan–Kettering experience. J Clin Oncol 1992;1:5-15.  Back to cited text no. 1
Bacci G, Ferrari S, Donati D, Longhi A, Bertoni F, Di Fiore, et al. Neoadjuvant chemotherapy for osteosarcoma of the extremity in patients in the fourth and fifth decade of life. Oncol Rep 1998;1:1259-63.  Back to cited text no. 2
Enneking WF. A system for the evaluation of the surgical management of musculoskeletal tumors. In: Enneking WF, editor. Limb salvage in musculoskeletal oncology. New York: Churchill Livingstone; 1987:626-39.  Back to cited text no. 3
Rosen G, Caparros B, Huvos AG, Kosloff C, Nirenberg A, Cacavio A, et al. Preoperative chemotherapy for osteogenic sarcoma: Selection of postoperative adjuvant chemotherapy based on the response of the primary tumor to preoperative chemotherapy. Cancer 1982;1:1221-30.  Back to cited text no. 4


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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