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< Back Dr. Fevzi SAGLAM Limb Salvage vs Amputation Limb salvage surgery has replaced amputation as the preferred approach for most malignant bone and soft tissue tumors, provided that oncologic safety can be maintained. Advances in imaging, chemotherapy, and reconstructive techniques have enabled wide resection with functional preservation in appropriately selected patients. Absolute indications for limb salvage include the ability to achieve negative margins without compromising major neurovascular structures, whereas amputation remains essential for cases with extensive involvement, infection, or unresectable disease. Long-term survival is comparable between limb salvage and amputation when clear margins are achieved, but limb salvage offers superior functional and cosmetic outcomes at the cost of higher complication rates. Future developments such as 3D-printed implants and biologic reconstructions are expected to further improve results, yet oncologic safety must always remain the primary goal. Limb Salvage and Amputation Orthopedic oncology is a multidisciplinary specialty concerned with the diagnosis and management of bone and soft tissue tumors. A pivotal decision in this field is whether the affected limb can be preserved or requires amputation. Historically, amputation was the standard treatment for malignant bone tumors. However, advances in imaging modalities, chemotherapy, radiotherapy, and surgical techniques have allowed limb salvage surgery to become a safe and effective alternative in many cases. The primary objective is to achieve oncologically safe resection margins while preserving limb function and appearance. Development and Indications of Limb Salvage Surgery Limb salvage surgery involves complete tumor excision with negative margins, followed by reconstruction of the resulting defect. The success of this procedure depends on tumor location, proximity to neurovascular structures, and patient-specific factors such as overall health and rehabilitation potential. Absolute Indications: • Tumor can be resected with safe margins without compromising major vessels or nerves. • Tumor reduction after neoadjuvant chemotherapy allows safe surgical margins. • Localized disease with no distant metastasis. Relative Indications: • Limited soft tissue involvement. • Absence of active infection or impaired wound healing. • Patient’s physical and psychological capacity for rehabilitation. Reconstruction techniques include modular tumor prostheses, autografts or allografts, rotationplasty, and vascularized fibular grafts. These strategies aim to restore limb length and maximize post-operative function. Indications and Role of Amputation Despite the advantages of limb salvage, amputation remains necessary in selected patients to ensure oncologic safety and optimal quality of life. Absolute indications include encasement of major neurovascular structures, uncontrolled infection, extensive soft tissue necrosis, or inability to achieve negative margins. Absolute Indications: • Tumor involving major arteries or nerves. • Widespread infection or chronic osteomyelitis. • Recurrent tumors where reconstruction is not feasible. • Inability to achieve oncologically safe margins. Relative Indications: • Patients with comorbidities precluding long or complex surgery. • Technical limitations preventing reconstruction. • Patient preference or anticipated noncompliance with rehabilitation. Modern prosthetic technology has significantly improved post-amputation functional outcomes and mobility. Oncologic and Functional Outcome Comparison Several studies have demonstrated no significant difference in long-term survival between limb salvage and amputation, provided negative surgical margins are achieved. Local recurrence risk remains primarily dependent on margin status. Functionally, limb salvage generally yields superior outcomes. Functional scores such as the Musculoskeletal Tumor Society (MSTS) score and Toronto Extremity Salvage Score (TESS) are typically higher in limb salvage patients (%70–80) compared to amputees (%50–60). However, limb salvage procedures are associated with higher rates of early complications including infection, prosthesis loosening, and mechanical failures. Amputation, conversely, presents fewer surgical complications but poses greater psychosocial adaptation challenges. Complications and Rehabilitation The most common complications after limb salvage surgery include wound healing problems, deep infections, implant loosening, and fractures. In pediatric patients, expandable prostheses are often employed to accommodate ongoing growth. After amputation, patients frequently encounter phantom limb pain, skin irritation, and challenges with prosthesis fitting. Rehabilitation requires a multidisciplinary approach involving physiotherapy, psychological support, and prosthetic training to optimize functional independence. Conclusion and Future Perspectives Limb salvage surgery in orthopedic oncology offers superior functional and aesthetic outcomes in appropriately selected patients. Individual patient assessment remains critical. Future advances, including 3D printing, biologic reconstruction, and improved understanding of chemoresistance mechanisms, are expected to enhance limb salvage success. Nonetheless, the fundamental principle remains unchanged: oncologic safety must always take precedence over functional preservation. References: 1. Simon MA, Aschliman MA, Thomas N, Mankin HJ. Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg Am. 1986;68(9):1331–1337. 2. Gonzalez, M. R., Mendez-Guerra, C., Goh, M. H., & Pretell-Mazzini, J. (2025). Principles of Surgical Treatment of Soft Tissue Sarcomas. Cancers , 17 (3), 401. 3. Grimer, R. J., Taminiau, A. M., & Cannon, S. R. (2002). Surgical outcomes in osteosarcoma. The Journal of Bone & Joint Surgery British Volume , 84 (3), 395-400. 4. Aksnes LH, Bauer HC, Jebsen NL, et al. Limb-sparing surgery preserves more function than amputation: a Scandinavian Sarcoma Group study of 118 patients. J Bone Joint Surg Br. 2008;90(6):786–794. 5. Chandrasekar CR, Grimer RJ, Carter SR, et al. Modular endoprosthetic replacement for tumours of the proximal femur. J Bone Joint Surg Br. 2009;91(1):108–112. 6. Malawer, M. M., & Sugarbaker, P. H. (Eds.). (2006). Musculoskeletal cancer surgery: treatment of sarcomas and allied diseases . Springer Science & Business Media. 7. Davis AM, Bell RS, Badley EM, et al. Evaluating functional outcome in patients with lower extremity sarcoma. Clin Orthop Relat Res. 1999;(358):90–100. 8. Cirstoiu, C., Cretu, B., Serban, B., Panti, Z., & Nica, M. (2019). Current review of surgical management options for extremity bone sarcomas. EFORT open reviews , 4 (5), 174-182. Previous Next

< Back Dr. Niyazi İğde Palliative Surgery Palliative surgery in orthopaedic oncology aims to relieve pain, preserve function, and improve quality of life in patients with advanced or incurable musculoskeletal malignancies. General Principles · Goal: Not curative, but aimed at improving quality of life. · Priorities: Pain control, restoration of function/mobility, prevention of complications. · Decision Basis: Expected survival, tumor type, anatomical site, patient performance status, and multidisciplinary evaluation. 1. Pathological Fractures Indications · Fractures due to metastatic lesions (especially in weight-bearing bones). · Severe pain, loss of function, or bed confinement. · If pain is controllable in terminal patients with very poor performance status → consider non-operative palliation (brace/orthosis, analgesia, radiotherapy). Surgical Goals · Pain palliation, reduction of opioid requirement. · Early mobilization, prevention of immobility-related complications. · Restoration of mechanical stability for the remainder of life. Preferred Techniques · Intramedullary Nailing: First-line for long bone fractures, spanning the entire bone. · Endoprosthesis (Joint Replacement): For intra-articular or periarticular fractures (e.g., proximal femur/humerus). · Cement Augmentation (PMMA): Fills defects, increases implant stability, provides immediate fixation. · Segmental Resection + Reconstruction: Rare, reserved for select cases (e.g., myeloma with healing potential). Key Considerations · Definitive diagnosis required: Biopsy before fixation. · Suspected primary tumors require oncologic (curative) approach if feasible. · Pre-op embolization for hypervascular tumors (renal, thyroid). · Post-op radiotherapy is frequently indicated. · Implants must provide stability throughout the patient’s expected survival. · Risks: poor bone integration, implant failure, wound healing issues, infection. 2. Impending (High-Risk) Fractures Indications · Cortical destruction >50%, lesion involving >2/3 of bone diameter, >2.5 cm lytic lesions. · Severe mechanical pain. · Critical sites: subtrochanteric femur, femoral neck, vertebrae. · Mirels Score ≥8 → strong indication for prophylactic fixation. Surgical Goals · Prevent fractures before they occur. · Reduce morbidity compared to post-fracture surgery. · Preserve function, maintain ambulation. · Allow continuation of systemic therapies without interruption. Preferred Techniques · Intramedullary Nailing: Standard for long bones. · Plates + Screws: In regions unsuitable for nailing, ideally cement-augmented. · Endoprosthesis: For periarticular lesions at high fracture risk (e.g., femoral neck, proximal humerus). · Cement Augmentation: Following curettage of cavities for added stability. Key Considerations · Not an emergency → allows for pre-op biopsy + staging. · Mirels ≤7: radiotherapy and close follow-up preferred. · Radiosensitive tumors (myeloma, lymphoma) often respond to radiotherapy alone. · Always combine with systemic therapy (chemotherapy, hormonal, bisphosphonates/denosumab). 3. Spinal Metastases Indications · Instability: SINS ≥13 → surgical stabilization; 7–12 → case-dependent. · Neurological Compression: Progressive weakness, paraplegia, sphincter dysfunction → urgent decompression + stabilization. · Intractable Pain: Not controlled by radiotherapy or medical management. Surgical Goals · Decompression of spinal cord/nerve roots. · Stabilization of spinal column, preventing deformity and mechanical pain. · Preservation or improvement of neurological function. · Enhanced quality of life. Preferred Techniques · Posterior Decompression + Instrumentation (two levels above and below). · Anterior Corpectomy + Cage/Plate (especially cervical or thoracolumbar). · Cement Augmentation (Vertebroplasty/Kyphoplasty): For pain relief when no neurological compression exists. · Pre-op Embolization: Strongly recommended for hypervascular metastases. Key Considerations · Apply the NOMS framework (Neurologic, Oncologic, Mechanical, Systemic). · Radiosensitive tumors (lymphoma, myeloma, prostate, breast) → consider radiotherapy first if no deficit. · Tokuhashi score for prognosis and extent of surgery. · High complication risks: wound issues, infection, implant failure → must weigh risks vs benefit. 4. Pelvic Metastases Indications · Periacetabular metastases with subchondral roof involvement (Harrington class II–III). · Severe pain, inability to mobilize. · Fungating, bleeding, or ulcerating local tumor masses. Surgical Goals · Pain palliation. · Restoration of hip stability for sitting, standing, or limited ambulation. · Debulking to reduce tumor burden. Preferred Techniques · Harrington Procedure + Cemented Prosthesis. · Cementoplasty: For localized lesions with intact subchondral bone. · Cemented THA (with cage/augment as needed). · Custom Tumor Prostheses: Reserved for advanced cases. · Minimally Invasive Acetabuloplasty: In poor surgical candidates. Key Considerations · Harrington classification guides technique selection. · High bleeding risk → pre-op embolization essential. · High infection risk → fill dead space, use prophylactic antibiotics. · Weight-bearing protocols individualized by intra-op stability. 5. Palliative Amputation (Primary Tumors) Indications · Locally uncontrolled tumors (progressive, painful, infected, or bleeding). · Severe pain and loss of function. · Fungating wounds with foul odor/discharge. · Non-salvageable complications (infected megaprosthesis). Surgical Goals · Pain control. · Elimination of infection, odor, bleeding. · Facilitate care and hygiene. · Restore limited mobility (wheelchair/prosthesis). · Psychosocial relief. Key Considerations · Amputation level: balance between adequate control and healing potential. · Multidisciplinary decision, family consent critical. · Expected survival should justify recovery from surgery. 6. Debulking / Revision Surgery Indications · Symptomatic bulky tumors causing compression, obstruction, or infection. · Implant breakage/loosening. · Local recurrence. · Prosthesis/implant infection. Surgical Goals · Symptom palliation (pain, mass effect, infection). · Maintenance of previously achieved function. · Preserve or restore quality of life. Techniques · Intralesional curettage + PMMA cementation. · Implant/prosthesis revision with stronger fixation. · Soft tissue debulking + flap reconstruction. · Minimally invasive ablation + cement augmentation when indicated. 7. Pediatric Patients · Indications similar to adults (fractures, instability, severe pain, compression). · Growth plate preservation whenever possible. · For limited survival, adult principles apply. · Always involve a multidisciplinary team and family. 8. Supportive Therapies · Radiotherapy: First-line for painful metastases; SBRT highly effective for spine. · Systemic therapy: Chemotherapy, hormonal therapy, immunotherapy. · Bone-targeted agents: Bisphosphonates, denosumab reduce fracture risk and pain. · Radionuclide therapies: Ra-223, Sm-153, Sr-89 (especially prostate/breast). · Analgesics: WHO ladder approach (non-opioid → opioid → strong opioid ± adjuvants). · Orthoses/Braces: For stabilization and pain relief when surgery not feasible. · Rehabilitation & Psychosocial Support: Essential for patient and family. Conclusion · Palliative orthopedic surgery is an active therapeutic intervention . · When properly indicated, it achieves: ➝ Pain relief ➝ Restoration of mobility ➝ Preservation of dignity and independence · Always individualized, multidisciplinary, and guided by the principle of “first, do no harm.” References Taitsman LA, Safran MR. Palliative surgery in orthopaedic oncology. J Am Acad Orthop Surg. 2010;18(6):400-410. Piccioli A, Maccauro G, Spinelli MS, Biagini R, Rossi B. Surgical management of metastatic bone disease: A comprehensive review. Surg Oncol. 2012;21(3):161-169. Coleman RE, Croucher PI, Padhani AR, et al. Bone metastases. Nat Rev Dis Primers. 2020;6(1):83. Errani C, Mavrogenis AF, Cevolani L, et al. Palliative treatment of skeletal metastases: Prognostic criteria and therapy. Int Orthop. 2015;39(9):1981-1987. Fourney DR, Frangou EM, Ryken TC, et al. Spinal instability neoplastic score: An analysis of reliability and validity from the spine oncology study group. Spine (Phila Pa 1976). 2011;36(22):E1221-1229. Previous Next

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Surgical Guide Total Hip Arthroplasty Introduction Bu bir paragraf. Bu metni değiştirmek veya düzenlemek için tıklayın. Çok kolay. Total Hip Arthroplasty Introduction Bu bir paragraf. Bu metni değiştirmek veya düzenlemek için tıklayın. Çok kolay. Total Hip Arthroplasty Introduction Bu bir paragraf. Bu metni değiştirmek veya düzenlemek için tıklayın. Çok kolay. Surgical Guide

< Back Dr. Korhan OZKAN Professor, M.D. Acıbadem Healthcare Group, Orthopaedics and Traumatology – Orthopaedic Oncology Location: Istanbul, Türkiye Education and Training 2013 – Medical University of Vienna , Orthopaedic Oncology Center, Austria 2012 – Royal Orthopaedic Hospital , Birmingham, United Kingdom 2011 – Universitätsklinikum Münster , Orthopaedic Oncology Center (Prof. Dr. Georg Gosheger), Germany 2005 – Istanbul University, Istanbul Faculty of Medicine , Department of Orthopaedics and Traumatology 2005 – Allgemeines und Orthopaedisches Landeskrankenhaus Stolzalpe (Prof. Reinhard Graf), Austria 2000 – Marmara University Faculty of Medicine , Istanbul, Türkiye Professional Experience 2023 – Present – Acıbadem Healthcare Group , Department of Orthopaedics and Traumatology 2006 – 2023 – Istanbul Medeniyet University, Göztepe Training and Research Hospital , Department of Orthopaedics and Traumatology 2006 – Zeynep Kamil Training and Research Hospital , Orthopaedic Surgeon 2006 – İznik State Hospital , Orthopaedic Surgeon 2005 – 2006 – Florence Nightingale Hospital , Department of Orthopaedics and Traumatology 2000 – 2005 – Istanbul University, Istanbul Faculty of Medicine , Research Assistant, Department of Orthopaedics and Traumatology https://www.ortopediktumor.com/ https://www.acibadem.com.tr/doktor/korhan-ozkan/ Oncologic Orthopaedics korhanozkan76@gmail.com Previous Next

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