Limb-sparing techniques

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Limb-sparing techniques, also known as limb-saving or limb-salvage techniques, are performed in order to preserve the look and function of limbs. [1] Limb-sparing techniques are used to preserve limbs affected by trauma, arthritis, cancers such as high-grade bone sarcomas, and vascular conditions such as diabetic foot ulcers. [2] As the techniques for chemotherapy, radiation, and diagnostic modalities improve, there has been a trend toward limb-sparing procedures to avoid amputation, [3] which has been associated with a lower 5-year survival rate [4] and cost-effectiveness [2] compared to limb salvage in the long-run. There are many different types of limb-sparing techniques, including arthrodesis, arthroplasty, endoprosthetic reconstruction, various types of implants, rotationplasty, osseointegration limb replacement, fasciotomy, and revascularization.

Contents

Arthrodesis

X-ray of a wrist that has undergone carpal arthrodesis (fusion of the wrist joint). In this case, this means that screws have been inserted through multiple wrist bones so they are now immobilized. Over time, these bones will fuse together, preventing them from rubbing against each other and causing pain. ScaphoidectomyWCarpalFusion 2 L.jpg
X-ray of a wrist that has undergone carpal arthrodesis (fusion of the wrist joint). In this case, this means that screws have been inserted through multiple wrist bones so they are now immobilized. Over time, these bones will fuse together, preventing them from rubbing against each other and causing pain.

Arthrodesis is the surgical immobilization of bones within a joint to promote fusion of the joint. [5] Arthrodesis is performed most commonly on joints of the feet, hands, and spine. [6] [7] [8] Arthrodesis can relieve pain from arthritis and fractures. [9] This is accomplished through the use of orthobiologics such as allografts and autografts. [10] Allografts are done by creating bone grafts from a donor bone bank, whereas autografts are bone grafts from other bones in a patient's body. [10] Patient-reported outcomes following this procedure are typically positive in terms of long-term pain relief; however, the procedure also results in decreased range of motion. [11]

Arthroplasty

Diagrams of the most common joints that undergo arthroplasty (joint replacement): shoulders, hips, and knees. Notice that the articular surface of each joint has been removed and replaced with metal and plastic implants to recreate the normal joint interface. Replacement surgery - Shoulder total hip and total knee replacement -- Smart-Servier (cropped).jpg
Diagrams of the most common joints that undergo arthroplasty (joint replacement): shoulders, hips, and knees. Notice that the articular surface of each joint has been removed and replaced with metal and plastic implants to recreate the normal joint interface.

Arthroplasty , otherwise known as joint replacement, is a surgical procedure which involves resurfacing, realignment, or removal of bone at a joint interface to restore the joint's function. [12] Arthroplasty is often performed on hips, knees, shoulders, and ankles to improve range of motion and relieve pain from arthritis or trauma. [13] [14] Arthroplasty of the shoulder is one of the most common of these procedures, although it has only been widely used since 1955. [15] Themistocles Gluck is thought to have created the first shoulder arthroplasty in the 1800s. [15] Since Gluck never published any results or notes on the procedure, Jules-Emile Pean is credited with performing the first shoulder arthroplasty in 1893. [15]

Implants

Alloprosthetic composites

Alloprosthetic composites are a combination of multiple limb-sparing techniques, namely allografts and prosthesis. Allografts are used to replace the bone that has been "resected" using arthroplasty techniques, and then prosthesis is used to support and strengthen the allografts. [16] Alloprosthetic composites are flexible in that surgeons can adapt the implants for any situation. [17]

Prosthetic implants

Prosthetic implants are used when sections of bone must be replaced and no further growth is expected. Implants are mostly made from metals, but the possibility of using ceramic material has been discussed among surgeons. Prosthetics can be temporary or permanent. Temporary implants remain in place until the bone has healed and are then removed. The temporary implants take most of the burden off of the fracture, causing the bone to become less dense. This can lead to re-fracturing of the bone after the implant is removed. The implants can also cause stress concentrations as a result of the material difference between the bone and the plate. With the permanent prostheses, a putty-like substance is injected into the implant site to keep the body, mainly the immune system, from fighting off the implant. This substance can deteriorate bony tissue and cause serious bone problems for the patient. Prosthetic limbs have been used for many years.

Diagram of workflow describing the basic process of 3D-printing an implant for the skull. Notice the use of the advanced computer software to create a 3-dimensional rendering of the part of the skull that will be printed. The rightmost photo depicts the 3D-printed implant placed on the actual skull. Xilloc Patient Specific Implant Titanium.png
Diagram of workflow describing the basic process of 3D-printing an implant for the skull. Notice the use of the advanced computer software to create a 3-dimensional rendering of the part of the skull that will be printed. The rightmost photo depicts the 3D-printed implant placed on the actual skull.

3D-printed implants

3D-printing leverages the power of computer rendering of advanced imaging to tailor implants to each patient, which can then be used to create a physical realization of that implant to use in that individual's surgery. [18] [19] 3D-printing of medical devices was first used in the 1990s for dental implants and custom prosthetics but has since been used for various bones and organs such as urinary bladders. [20] [21] [22]

Rotationplasty

Rotationplasty , more commonly known as Van-Nes or Borggreve Rotation, is a limb-sparing medical procedure performed when a patient's leg is amputated at the knee. [23] The ankle joint is then rotated 180 degrees and is attached to the former knee joint, becoming a new knee joint. [23] This allows patients to have two fully functional feet, as opposed to losing one leg completely to amputation. [24]

Reasons for rotationplasty

Originally, rotationplasty was performed to treat infections and tumors around the knee, especially osteosarcoma of the knee. [25] While it is still being used to treat their complications, rotationplasty is also used to treat growing children who have been diagnosed with tumors around the knee. [26] Rotationplasty is also performed on children with congenital femoral deficiencies, such as those that cause unstable hip joints or limb-length discrepancy of the femur. [27] This procedure gives patients the ability to retain the use of both feet, allowing them to continue living an active lifestyle.

History of rotationplasty

Rotationplasty was first performed by Borggreve in the early 1900s on a 12-year-old boy with tuberculosis. [28] However, the procedure was not well known until 1950. At that time, physician Van Nes reported the results of rotationplasty procedures and became well known for founding the procedure. Since then, many surgeons have performed modified versions of rotationplasty and have had great success. [29]

Rotationplasty procedure

In the actual procedure, the bone affected by the tumor, as well as a small part of the healthy femur and occasionally tibia bone, is removed. [30] The ankle joint is then turned 180 degrees and is reattached to the thigh. [30] They are held together by plates and screws until they have healed naturally. The surgery can take anywhere from 6–10 hours, with a day or two in intensive care. [26] The leg is kept in a cast for 6–12 weeks. After the leg has sufficiently healed, the leg can be fitted for a prosthetic. [29]

Advantages and disadvantages of rotationplasty

In the same scenario, amputation would not leave a knee joint. Rotationplasty retains the use of a knee joint. Furthermore, it provides a better position for a prosthetic limb compared to amputation. [30] As a result, children who have had rotationplasty can return to their previous activities such as playing sports and avoid undergoing additional surgeries throughout their lives. Rotationplasty is also durable [26] and has been associated with enhanced quality of life and life contentment. [31] Unfortunately, not every case turns out favorably. Rotationplasty can result in problems with blood supply to the leg, infection, nerve injuries, problems with bone healing, and fracture of the leg. [32]

Related Research Articles

<span class="mw-page-title-main">Amputation</span> Medical procedure that removes a part of the body

Amputation is the removal of a limb by trauma, medical illness, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventive surgery for such problems. A special case is that of congenital amputation, a congenital disorder, where fetal limbs have been cut off by constrictive bands. In some countries, amputation is currently used to punish people who commit crimes. Amputation has also been used as a tactic in war and acts of terrorism; it may also occur as a war injury. In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment. When done by a person, the person executing the amputation is an amputator. The oldest evidence of this practice comes from a skeleton found buried in Liang Tebo cave, East Kalimantan, Indonesian Borneo dating back to at least 31,000 years ago, where it was done when the amputee was a young child.

<span class="mw-page-title-main">Prosthesis</span> Artificial device that replaces a missing body part

In medicine, a prosthesis, or a prosthetic implant, is an artificial device that replaces a missing body part, which may be lost through trauma, disease, or a condition present at birth. Prostheses are intended to restore the normal functions of the missing body part. Amputee rehabilitation is primarily coordinated by a physiatrist as part of an inter-disciplinary team consisting of physiatrists, prosthetists, nurses, physical therapists, and occupational therapists. Prostheses can be created by hand or with computer-aided design (CAD), a software interface that helps creators design and analyze the creation with computer-generated 2-D and 3-D graphics as well as analysis and optimization tools.

<span class="mw-page-title-main">Orthopedic surgery</span> Branch of surgery concerned with the musculoskeletal and bones system

Orthopedic surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal trauma, spine diseases, sports injuries, degenerative diseases, infections, tumors, and congenital disorders.

<span class="mw-page-title-main">Hip replacement</span> Surgery replacing hip joint with prosthetic implant

Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant, that is, a hip prosthesis. Hip replacement surgery can be performed as a total replacement or a hemi/semi(half) replacement. Such joint replacement orthopaedic surgery is generally conducted to relieve arthritis pain or in some hip fractures. A total hip replacement consists of replacing both the acetabulum and the femoral head while hemiarthroplasty generally only replaces the femoral head. Hip replacement is one of the most common orthopaedic operations, though patient satisfaction varies widely. Approximately 58% of total hip replacements are estimated to last 25 years. The average cost of a total hip replacement in 2012 was $40,364 in the United States, and about $7,700 to $12,000 in most European countries.

<span class="mw-page-title-main">Bone grafting</span> Bone transplant

Bone grafting is a surgical procedure that replaces missing bone in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly. Some small or acute fractures can be cured without bone grafting, but the risk is greater for large fractures like compound fractures.

<span class="mw-page-title-main">Arthrodesis</span>

Arthrodesis, also known as artificial ankylosis or syndesis, is the artificial induction of joint ossification between two bones by surgery. This is done to relieve intractable pain in a joint which cannot be managed by pain medication, splints, or other normally indicated treatments. The typical causes of such pain are fractures which disrupt the joint, severe sprains, and arthritis. It is most commonly performed on joints in the spine, hand, ankle, and foot. Historically, knee and hip arthrodeses were also performed as pain-relieving procedures, but with the great successes achieved in hip and knee arthroplasty, arthrodesis of these large joints has fallen out of favour as a primary procedure, and now is only used as a procedure of last resort in some failed arthroplasties.

<span class="mw-page-title-main">Knee replacement</span> Surgical procedure

Knee replacement, also known as knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability, most commonly offered when joint pain is not diminished by conservative sources. It may also be performed for other knee diseases, such as rheumatoid arthritis. In patients with severe deformity from advanced rheumatoid arthritis, trauma, or long-standing osteoarthritis, the surgery may be more complicated and carry higher risk. Osteoporosis does not typically cause knee pain, deformity, or inflammation, and is not a reason to perform knee replacement.

<span class="mw-page-title-main">Computer-assisted orthopedic surgery</span>

Computer-assisted orthopedic surgery or computer-assisted orthopaedic surgery is a discipline where computer technology is applied pre-, intra- and/or post-operatively to improve the outcome of orthopedic surgical procedures. Although records show that it has been implemented since the 1990s, CAOS is still an active research discipline which brings together orthopedic practitioners with traditionally technical disciplines, such as engineering, computer science and robotics.

<span class="mw-page-title-main">Joint replacement</span> Orthopedic surgery to replace a joint

Joint replacement is a procedure of orthopedic surgery known also as arthroplasty, in which an arthritic or dysfunctional joint surface is replaced with an orthopedic prosthesis. Joint replacement is considered as a treatment when severe joint pain or dysfunction is not alleviated by less-invasive therapies. Joint replacement surgery is often indicated from various joint diseases, including osteoarthritis and rheumatoid arthritis.

Rotationplasty, commonly known as a Van Nes rotation or Borggreve rotation, is a type of autograft wherein a portion of a limb is removed, while the remaining limb below the involved portion is rotated and reattached. This procedure is used when a portion of an extremity is injured or involved with a disease, such as cancer.

<span class="mw-page-title-main">Hallux rigidus</span> Medical condition

Hallux rigidus or stiff big toe is degenerative arthritis and stiffness due to bone spurs that affects the metatarsophalangeal joints (MTP) at the base of the hallux.

<span class="mw-page-title-main">Shoulder replacement</span>

Shoulder replacement is a surgical procedure in which all or part of the glenohumeral joint is replaced by a prosthetic implant. Such joint replacement surgery generally is conducted to relieve arthritis pain or fix severe physical joint damage.

Epiphysiodesis is a pediatric orthopedic surgery procedure that aims at altering or stopping the bone growth naturally occurring through the growth plate also known as the physeal plate. There are two types of epiphysiodesis: temporary hemiepiphysiodesis and permanent epiphysiodesis. Temporary hemiepiphysiodesis is also known as guided growth surgery or growth modulation surgery. Temporary hemiepiphysiodesis is reversible i.e. the metal implants used to achieve epiphysiodesis can be removed after the desired correction is achieved and the growth plate can thus resume its normal growth and function. In contrast, permanent epiphysiodesis is irreversible and the growth plate function cannot be restored after surgery. Both temporary hemiepiphysiodesis and permanent epiphysiodesis are used to treat a diverse array of pediatric orthopedic disorders but the exact indications for each procedure are different.

Ankle replacement, or ankle arthroplasty, is a surgical procedure to replace the damaged articular surfaces of the human ankle joint with prosthetic components. This procedure is becoming the treatment of choice for patients requiring arthroplasty, replacing the conventional use of arthrodesis, i.e. fusion of the bones. The restoration of range of motion is the key feature in favor of ankle replacement with respect to arthrodesis. However, clinical evidence of the superiority of the former has only been demonstrated for particular isolated implant designs.

"Professor" Derek McMinn is a British orthopaedic surgeon and inventor who practised in Birmingham, United Kingdom at the BMI Edgbaston Hospital until his suspension in 2020. McMinn is currently under police investigation for allegedly keeping the body parts of thousands of patients over a 25-year period.

The following outline is provided as an overview of and topical guide to trauma and orthopaedics:

<span class="mw-page-title-main">Index of trauma and orthopaedics articles</span>

Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.

<span class="mw-page-title-main">Reverse shoulder replacement</span>

Reverse shoulder replacement is a type of shoulder replacement in which the normal ball and socket relationship of glenohumeral joint is reversed, creating a more stable joint with a fixed fulcrum. This form of shoulder replacement is utilized in situations in which conventional shoulder replacement surgery would lead to poor outcomes and high failure rates.

Ankle fusion, or ankle arthrodesis, is surgery of the ankle to fuse the bones to treat arthritis and for other purposes. There are different types of ankle fusion surgery. The surgery involves the use of screws, plates, medical nails, and other hardware to achieve bone union. Ankle fusion is considered to be the gold standard for treatment of end-stage ankle arthritis. It trades joint mobility for relief from pain. Complications may include infection, non-union, and, rarely, amputation.

References

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  2. 1 2 Kadam, Dinesh (May 2013). "Limb salvage surgery". Indian Journal of Plastic Surgery. 46 (2): 265–274. doi: 10.4103/0970-0358.118603 . ISSN   0970-0358. PMC   3901908 . PMID   24501463.
  3. ↑ Kauvar, David S.; Propper, Brandon W. (2022-01-01), Rasmussen, Todd E.; Tai, Nigel R. M. (eds.), "22 - Lower Extremity Vascular Trauma", Rich's Vascular Trauma (Fourth Edition), Philadelphia: Elsevier, pp. 273–287, ISBN   978-0-323-69766-8 , retrieved 2023-01-13
  4. ↑ Han, Gang; Bi, Wen-Zhi; Xu, Meng; Jia, Jin-Peng; Wang, Yan (2016-04-26). "Amputation Versus Limb-Salvage Surgery in Patients with Osteosarcoma: A Meta-analysis". World Journal of Surgery. 40 (8): 2016–2027. doi:10.1007/s00268-016-3500-7. ISSN   1432-2323. PMID   27116252. S2CID   5737283.
  5. ↑ Chambers, Aaron R.; Dreyer, Mark A. (2022), "Triple Arthrodesis", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   31869177 , retrieved 2023-01-17
  6. ↑ Goyal, Nikhil; Bali, Shivkumar; Ahuja, Kaustubh; Chaudhary, Sunny; Barik, Sitanshu; Kandwal, Pankaj (2021). "Posterior Arthrodesis of Atlantoaxial Joint in Congenital Atlantoaxial Instability Under 5 Years of Age: A Systematic Review". Journal of Pediatric Neurosciences. 16 (2): 97–105. doi: 10.4103/jpn.JPN_270_20 . ISSN   1817-1745. PMC   8706584 . PMID   35018176.
  7. ↑ Faulkner, Harrison; An, Vincent; Lawson, Richard; Graham, David; Sivakumar, Brahman (2021-03-07). "Proximal Interphalangeal Joint Arthrodesis Techniques: A Systematic Review". Hand. 18 (1): 74–79. doi:10.1177/1558944721998019. ISSN   1558-9455. PMC   9806530 . PMID   33682483.
  8. ↑ Shih, Chia-Lung; Chen, Shu-Jung; Huang, Peng-Ju (2020). "Clinical Outcomes of Total Ankle Arthroplasty Versus Ankle Arthrodesis for the Treatment of End-Stage Ankle Arthritis in the Last Decade: a Systematic Review and Meta-analysis". The Journal of Foot and Ankle Surgery. 59 (5): 1032–1039. doi:10.1053/j.jfas.2019.10.008. ISSN   1542-2224. PMID   32709528. S2CID   225584427.
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  16. ↑ Janssen, Stein; Langerhuizen, David; Schwab, Joseph; Bramer, Jos (2019-07-07). "Outcome after reconstruction of proximal femoral tumors: A systematic review". Journal of Surgical Oncology. 119 (1): 120–129. doi:10.1002/jso.25297. ISSN   1096-9098. PMID   30466190. S2CID   53713781.
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  24. ↑ Gaillard, Jean; Fouasson-Chailloux, Alban; Eveno, Dominique; Bokobza, Guillaume; Da Costa, Marta; Heidar, Romain; Pouedras, Marie; Nich, Christophe; Gouin, François; Crenn, Vincent (2022). "Rotationplasty Salvage Procedure as an Effective Alternative to Femoral Amputation in an Adult With a History of Osteosarcoma: A Case Report and Review". Frontiers in Surgery. 8: 820019. doi: 10.3389/fsurg.2021.820019 . ISSN   2296-875X. PMC   8776644 . PMID   35071319.
  25. ↑ Ramseier, Leonhard E.; Dumont, Charles E.; Ulrich Exner, G. (2008). "Rotationplasty (Borggreve/Van Nes and modifications) as an alternative to amputation in failed reconstructions after resection of tumours around the knee joint". Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery. 42 (4): 199–201. doi:10.1080/02844310802069434. PMID   18763196. S2CID   10486883.
  26. 1 2 3 Soni, Emily. "A Surgeon's Approach – The Dynamics of Rotationplasty." Rotationplasty. N.p., 2011. Web. 19 Oct 2011. <http://www.rotationplasty.org/A-Surgeons-Approach--The-Dynamics-of-Rotationplasty>.
  27. ↑ Brown, Kenneth L.B. (2001). "Resection, Rotationplasty, and Femoropelvic Arthrodesis in Severe Congenital Femoral Deficiency". The Journal of Bone and Joint Surgery-American Volume. 83 (1): 78–85. doi:10.2106/00004623-200101000-00011. PMID   11205862. S2CID   23701234.
  28. ↑ Borggreve, J (1930-01-01). "Kniegelenksersatz durch das in der Beinlängsachse um 180° gedrehte Fußgelenk". Archiv für Orthopädische und Unfall-Chirurgie. 28: 175–178. doi:10.1007/BF02581614. S2CID   40801977 – via Google Scholar.
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  30. 1 2 3 Bernthal, Nicholas; Monument, Michael; Randall, R. Lor; Jones, Kevin (2014-06-01). "Rotationplasty: Beauty is in the Eye of the Beholder". Operative Techniques in Orthopaedics. 24 (2): 103–110. doi:10.1053/j.oto.2013.11.001. PMC   4234076 . PMID   25414567.
  31. ↑ Rödl, Robert W.; Pohlmann, Ursula; Gosheger, Georg; Lindner, Norbert J.; Winkelmann, Winfried (2002). "Rotationplasty--quality of life after 10 years in 22 patients". Acta Orthopaedica Scandinavica. 73 (1): 85–88. doi: 10.1080/000164702317281468 . PMID   11928918. S2CID   30887593.
  32. ↑ Hillmann, A.; Gosheger, G.; Hoffmann, C.; Ozaki, T.; Winkelmann, W. (2000). "Rotationplasty - surgical treatment modality after failed limb salvage procedure". Archives of Orthopaedic and Trauma Surgery. 120 (10): 555–558. doi:10.1007/s004020000175. PMID   11110135. S2CID   6829184.
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