Surgical Reconstruction After Tumor Resection

Principles of Reconstruction - Blueprint for Bones

• Primary Goals:
  • Oncological: Ensure adequate tumor margins (R0 resection).
  • Functional: Restore limb function, stability, and pain-free motion.
  • Durability: Provide a long-lasting construct, minimizing complications.
• Influencing Factors:
  • Patient: Age, comorbidities, functional demands, bone stock.
  • Tumor: Type, grade, stage, location, size of defect.
  • Soft tissue: Quality and quantity of coverage.
• Timing:
  • Immediate: Ideal for most; single-stage procedure.
  • Delayed: If infection, inadequate soft tissue, or patient instability.

⭐ The "Reconstructive Ladder" principle guides choice: simplest effective method first, aiming for optimal outcome with least morbidity.

Reconstructive Options - The Bone Builder's Toolkit

Options restore form/function post-resection, from biological grafts to metallic implants, based on defect & patient.

Limb Salvage Surgery - Saving vs. Sacrificing

Limb Salvage Surgery (LSS) involves complete tumor resection with adequate margins, aiming to preserve a functional extremity. Amputation is considered when LSS is not feasible or oncologically unsafe.

• Indications for LSS:
  • Resectable tumor with clear margins.
  • Intact or reconstructible neurovascular structures.
  • Adequate soft tissue and bone for reconstruction.
  • Patient preference and good functional prognosis.
• Contraindications for LSS:
  • Extensive neurovascular encasement.
  • Pathological fracture with gross contamination.
  • Uncontrolled infection.
  • Poor patient compliance or severe comorbidities.
• MSTS Score: Functional assessment post-LSS; score >75% suggests good outcome.

⭐ Local recurrence is the most common cause of LSS failure, followed by infection and implant failure.

Complications & Outcomes - The Aftermath & Outlook

• Immediate & Early Complications:
  • Infection (Surgical Site Infection: ~5-15%)
  • Wound issues (dehiscence, hematoma)
  • Neurovascular injury, Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
• Late Complications:
  • Implant-Related:
    • Aseptic loosening
    • Structural failure (breakage, wear)
    • Periprosthetic fracture

  ⭐ Aseptic loosening is the most common cause of long-term failure for endoprosthetic reconstructions after tumor resection.

  • Tumor-Related:
    • Local recurrence (e.g., <10% with wide margins for sarcomas)
    • Metastasis
• Functional Outcome:
  • Assessed by MSTS (Musculoskeletal Tumor Society), TESS (Toronto Extremity Salvage Score) scores.
  • Influenced by: tumor factors, reconstruction type, nerve status, rehabilitation.
• Overall Survival:
  • Variable (e.g., Osteosarcoma 5-year survival ~60-70%).

High‑Yield Points - ⚡ Biggest Takeaways

• Reconstruction aims: Limb salvage, restoring function, stability, and achieving local tumor control.
• Enneking classification guides resection and choice of reconstructive technique.
• Key options: Endoprosthetic replacement (EPR), allografts, arthrodesis, rotationplasty.
• EPR is common for joint preservation following wide excision of tumors.
• Major risks: Infection, implant loosening/failure, periprosthetic fracture, allograft non-union.
• Adequate surgical margins are critical to prevent local recurrence.
• Amputation: for unresectable tumors or failed limb salvage.