Orthopaedic Oncology is a precise speciality which deals with managing of Sarcomas, other bone and soft tissue tumours. Statistics on sarcomas in India are difficult to tabulate though it is said to account for 1-2% of all cancers in body. The rarity of this condition makes the treatment haphazard in various settings. The most common age is adolescence and the most common symptom to watch for is a non-mechanical night pain. Limb salvage surgery is one of the main key aspects of the management. All the cases handled in this speciality requires a multi-pronged approach. Only when it’s done as a multidisciplinary speciality, it’s worth treating these complex diseases. The long term results of sarcomas are one of the best if treated in right way at right time and the first time.
The lack of multidisciplinary settings in our country makes treatment of these diseases difficult. At HCG because of the multidisciplinary team [MDT] approach we are able to achieve results on par with the western standards and manage even the most complicated cases. The requirement of advanced imaging like 3T MRI, PET scan, advanced diagnostics including Sarcoma pathology, cytogenetics and gene analysis, the technicalities of bone banking and skills of limb salvage surgeries is the necessity in achieving a good cure rates.
One such case is Ms. Maheram [ Name changed] who is a 20 year old medical student, right hand dominant was treated as a benign tumour of Right elbow [ Fig 1]because of diagnostic difficulties. She was referred to our centre when she was asked to amputate in many centres across the world. She was evaluated by doing the standard set of investigations like Xray, 3T local MRI and a Whole body PETCT scan [Fig 2]. Following the radiological imaging, image guided ‘J' needle biopsy was done. The case was discussed in sarcoma multidisciplinary meeting and was diagnosed to have Classical osteosarcoma - Intermediate grade of the ulna which in fact is one of the aggressive malignant tumours of bone. Fortunately she was not metastatic and she was put on neo adjuvant chemotherapy with high dose Methotrexate regimen in an attempt to do limb salvage surgery. Post adjuvant chemotherapy showed a moderate clinical response in view of decrease in swelling size and radiologically there was increased sclerosis in X-ray. PET showed a mild response. The case was discussed across the world and to save her limb was very controversial considering the size, close proximity to nerves and a complex joint to reconstruct. After discussing with the patient and her parents, an attempt to limb salvage was planned with a planned R0 resection as a main aim. We planned to reconstruct using allograft prosthetic composite [APC]. We ordered for a custom elbow joint and Fresh frozen allograft of the elbow was used to reconstruct the Triceps and Brachialis. [Fig 3]
Surgically the case was planned with a medial approach, considering the scar and the access to nerves and vessels. The nerves were microsurgically isolated ulnar, median and radial in serially. The brachial artery was dissected and radial artery was saved. The bone cuts were done in radius, ulna and humerus [ Extraarticular tumour resection of elbow] and the tumour was removed with surgical R0 which was confirmed Histopathologically. As planned the tumour was reconstructed by APC. Triceps and Biceps were sutured to the allograft stubs for the elbow function. The patient tolerated the procedure well and physiotherapy program was initiated accordingly. At 6 months followup, the patient is disease free and she has an elbow function of 20-100 degrees. [ Figure 4].
The limb salvage was really difficult as the tumour size was big, recurrent and in a complicated area of proximal forearm. The fresh frozen allograft is a very important part of reconstruction in orthopaedic oncology.
In this part of the world there is no fresh bone bank. HCG in collaboration with IOR is in the development of a bone bank which is a must for an orthopaedic oncology department and to have that a nation should have a good organ donation program. ‘I pledge to save 12 ‘is a nationwide campaign initiated by HCG Foundation by take a pledge to donate organs.
The patient underwent the surgery successfully. The total duration of the surgery was 12 hours and she had an allograft prosthetic composite reconstruction to have the best of the function. All the nerves were spared and she has a fully functional hand and a near normal elbow for daily activities for a medical student. She was advised to continue her chemotherapy.
Figure 1. Clinical Photo of the elbow
Figure 2 . CT and PET Image findings of the elbow
Figure 3. Custom made Prosthesis (a), Allograft (b) and Post reconstruction (c) of the elbow
Figure 4. Post operative X-Ray & Clinical range of Motion after 6 months followup.
Osteosarcoma of the elbow is a rare site [3 cases out of 2328 cases seen in istituto Ortopedico rizzoli over 106 years of statistics]. The management of the same in that area is a difficult aspect to remove entoto and reconstruct. The complexity of this area is mainly because of so most cases end up in an above elbow amputation so was advised to this patient across the world. The advances in imaging , allograft and custom implant designing and the surgical techniques have made us think beyond the mark. The patient with right handed dominant medical student was decided for limb salvage surgery in personalised manner after serial discussion in tumour board and withvarious specialities.
Dr Pramod S. Chinder - Orthopaedic Oncosurgery
Dr MuraliKrishna - Vascular Surgeon
Dr Prashanth Puranik - Plastic Surgeon
Dr Ashok R - Orthopaedic Surgeon
Orthopaedic Onco Team - Aasim, Yeshwanth, Manu