Limb Salvage Surgery — MCQs
Amputation is often not required in:
The commando operation is:
Most sensitive modality for detecting bone metastases
Extensive surgical debridement, decompression or amputation may be indicated in the following clinical setting except
All of the following are described surgical procedures for CTE V except -
Surgery was performed as shown in the image below. What is the name of the procedure?
Distant bone metastases can be best detected by which of the following imaging techniques?
Most common site of osteogenic sarcoma is:
What is the most appropriate treatment for a soap bubble appearance at the lower end of the radius?
In the treatment of osteosarcoma, all of the following chemotherapy agents are used EXCEPT:
Limb Salvage Surgery Indian Medical PG Practice Questions and MCQs
Question 1: Amputation is often not required in:
- A. Buerger's
- B. Chronic osteomyelitis (Correct Answer)
- C. Diabetic gangrene
- D. Gas gangrene
Explanation: ***Chronic osteomyelitis*** - While chronic osteomyelitis can be severe, advancements in **antibiotic therapy**, **surgical debridement**, and **reconstructive procedures** often allow for limb salvage. - The goal of treatment is to eradicate infection and preserve function, making amputation a last resort when other methods fail to control infection or restore viability. *Buerger's* - **Buerger's disease** (thromboangiitis obliterans) is characterized by inflammation and thrombosis of small and medium-sized arteries and veins, primarily in the limbs, leading to severe ischemia and gangrene. - Due to progressive vascular damage and frequent lack of effective medical treatment for advanced stages, **amputation is often required** to remove necrotic tissue and manage intractable pain. *diabetic gangrene* - **Diabetic gangrene** results from a combination of **peripheral neuropathy**, **peripheral arterial disease**, and **infection**, leading to tissue death, particularly in the feet. - The compromised blood supply and impaired wound healing in diabetic patients make these lesions prone to rapid progression and severe infection, with **amputation frequently necessary** to prevent systemic sepsis and death. *Gas gangrene* - **Gas gangrene** is a rapidly progressive and life-threatening infection caused by *Clostridium* species, which produce toxins and gas within tissues. - Due to its aggressive and destructive nature, requiring immediate and extensive surgical debridement often involving **amputation of the affected limb** to remove all infected tissue and prevent widespread systemic toxicity.
Question 2: The commando operation is:
- A. Abdomino-perineal resection of the rectum for carcinoma
- B. Extended radical mastectomy
- C. Disarticulation of the hip for gas gangrene of the leg
- D. Excision of carcinoma of the tongue, the floor of the mouth, part of the jaw and lymph nodes en bloc (Correct Answer)
Explanation: ***Excision of carcinoma of the tongue, the floor of the mouth, part of the jaw and lymph nodes en bloc*** - The **Commando operation** specifically refers to a radical surgical procedure for advanced head and neck cancers, typically involving the **tongue**, **floor of the mouth**, and often requiring removal of a portion of the **mandible (jaw)** and a **neck dissection (lymph nodes en bloc)**. - This extensive, single-block resection aims to provide wide margins for large or invasive tumors in the oral cavity. *Abdomino-perineal resection of the rectum for carcinoma* - This procedure, known as **APR**, is a common surgery for low rectal cancers but is not referred to as a "Commando operation." - It involves the removal of the rectum and anus through both abdominal and perineal incisions, usually resulting in a permanent colostomy. *Extended radical mastectomy* - **Extended radical mastectomy** involves the removal of the breast, axillary lymph nodes, and potentially some chest wall muscles, but it is a procedure for breast cancer and not related to head and neck surgery, nor is it termed a "Commando operation." - This operation is a historically significant, though less common, approach to breast cancer management. *Disarticulation of the hip for gas gangrene of the leg* - **Hip disarticulation** is an amputation procedure at the hip joint for severe conditions like gas gangrene or extensive trauma and is not known as a "Commando operation." - This is an emergency or salvage procedure aimed at preventing further spread of infection or disease.
Question 3: Most sensitive modality for detecting bone metastases
- A. Bone scan
- B. PET-CT
- C. Plain radiograph
- D. MRI (Correct Answer)
Explanation: ***MRI*** - **MRI**, especially **whole-body MRI (WB-MRI)**, has the **highest sensitivity (90-100%)** for detecting bone metastases among all imaging modalities. - It directly visualizes **bone marrow changes** before cortical bone destruction occurs, allowing for earlier detection than other modalities. - Excellent for detecting both **lytic and sclerotic lesions** and provides superior soft tissue contrast for assessing marrow involvement. - Particularly sensitive for **spine and pelvic metastases**, and whole-body protocols enable comprehensive skeletal assessment. *PET-CT* - **PET-CT with 18F-FDG** is highly sensitive for detecting metabolically active lesions and provides whole-body assessment with both metabolic and anatomical information. - However, its sensitivity varies by primary tumor type and is **limited for sclerotic/osteoblastic metastases** which may not be FDG-avid. - While excellent for many malignancies, it has **lower sensitivity than MRI** for pure bone metastases detection, particularly in low-metabolism lesions. *Bone scan* - **Bone scan (Tc-99m MDP)** detects increased osteoblastic activity and has been the traditional screening tool with good sensitivity (62-89%). - Effective for detecting osteoblastic lesions and provides whole-body skeletal survey at relatively low cost. - However, it is **less sensitive than MRI** and can miss purely lytic metastases or early marrow involvement before osteoblastic response occurs. *Plain radiograph* - **Plain radiographs** require significant bone mineral loss (30-50%) to visualize lesions, making them the **least sensitive modality** for bone metastases. - Useful for assessing established lesions and complications like pathological fractures, but inadequate for screening or early detection.
Question 4: Extensive surgical debridement, decompression or amputation may be indicated in the following clinical setting except
- A. Acute rhabdomyolysis
- B. Acute haemolytic streptococcal cellulitis
- C. Acute thrombophlebitis (Correct Answer)
- D. Progressive synergistic gangrene
Explanation: ***Acute thrombophlebitis*** - This condition involves inflammation and **thrombosis** of a superficial vein, typically managed with **anticoagulation**, pain relief, and local measures. - Surgical intervention like debridement, decompression, or amputation is generally **not indicated** unless there are severe complications such as infection or extensive tissue necrosis, which are rare. *Acute rhabdomyolysis* - Severe rhabdomyolysis can lead to **compartment syndrome**, necessitating fasciotomy (decompression) to prevent irreversible muscle and nerve damage. - In cases of extensive muscle necrosis, **surgical debridement** may be required to remove non-viable tissue and prevent further systemic complications. *Acute haemolytic streptococcal cellulitis* - While initial management is antibiotics, rapidly progressing necrotizing infections (like **necrotizing fasciitis**, a severe form often caused by *Streptococcus pyogenes*) require **extensive surgical debridement** to remove dead tissue and control the spread of infection. - Delayed debridement can lead to systemic toxicity, limb loss, or death, making aggressive surgical intervention crucial. *Progressive synergistic gangrene* - Also known as **Meleney's gangrene**, this rare but severe soft tissue infection requires aggressive and **extensive surgical debridement** of all necrotic tissue. - The combination of aerobic and anaerobic bacteria creates a progressive, destructive lesion that can necessitate amputation if not adequately controlled by debridement.
Question 5: All of the following are described surgical procedures for CTE V except -
- A. Dwyer's osteotomy
- B. Salter's osteotomy (Correct Answer)
- C. Posteromedial soft tissue release
- D. Triple Arthrodesis
Explanation: ***Salter's osteotomy*** - **Salter's osteotomy** is a procedure primarily used for treating **developmental dysplasia of the hip (DDH)**, aiming to redirect the acetabulum. - It is not a described surgical procedure for the correction of **congenital talipes equinovarus (CTEV)**. *Dwyer's osteotomy* - **Dwyer's osteotomy** is a surgical procedure performed on the **calcaneus** to correct **hindfoot varus**, typically seen in CTEV. - It involves removing a wedge of bone from the lateral aspect of the calcaneus. *Posteromedial soft tissue release* - This is a common and traditional surgical procedure for correcting severe **CTEV** by addressing the contracted soft tissues on the medial and posterior aspects of the foot. - It involves releasing structures such as the **tibial tendon**, **flexor digitorum longus**, **flexor hallucis longus**, and the **posterior ankle joint capsule**. *Triple Arthrodesis* - **Triple arthrodesis** is a salvage procedure that involves fusing three joints in the foot: the **talonavicular**, **calcaneocuboid**, and **subtalar** joints. - It is used in older children or adolescents with severe, rigid, or recurrent CTEV, often after failed conservative or primary surgical treatments.
Question 6: Surgery was performed as shown in the image below. What is the name of the procedure?
- A. Below knee amputation
- B. Above knee amputation
- C. Lisfranc amputation
- D. Chopart amputation (Correct Answer)
Explanation: ***Chopart amputation*** - The image shows a disarticulation through the **talonavicular and calcaneocuboid joints**, which defines a **Chopart amputation**. - This procedure removes the distal foot while preserving the **calcaneus and talus**, forming a stump that allows for some ankle motion. *Below knee amputation* - A below-knee amputation involves transection of the tibia and fibula, preserving the knee joint, which is much more proximal than shown in the image. - This type of amputation removes a significant portion of the lower leg, with the foot entirely removed, unlike the partial foot amputation depicted. *Above knee amputation* - An above-knee amputation involves disarticulation or transection through the femur, completely removing the lower leg and knee joint. - This is a much more extensive amputation than what is illustrated, which is confined to the foot. *Lisfranc amputation* - A Lisfranc amputation is a disarticulation through the **tarsometatarsal joints**, removing the metatarsals and phalanges but preserving the tarsal bones. - The image clearly shows the incision more proximally, at the midtarsal level, specifically through the talonavicular and calcaneocuboid joints, not the tarsometatarsal joints.
Question 7: Distant bone metastases can be best detected by which of the following imaging techniques?
- A. Bone scan (Correct Answer)
- B. CT
- C. Intravenous venogram
- D. PET scan
Explanation: ***Bone scan*** - A **bone scan** is highly sensitive for detecting **osteoblastic activity**, which is characteristic of most bone metastases. - It involves injecting a **radioactive tracer** (usually technetium-99m methylene diphosphonate) that accumulates in areas of increased bone turnover, making it excellent for surveying the entire skeletal system. *PET scan* - While a **PET scan** (Positron Emission Tomography) can detect bone metastases, especially with **FDG-PET**, it is generally more expensive and may not be as sensitive for purely **osteoblastic lesions** as a bone scan. - Its primary role is often in assessing metabolic activity of the primary tumor and other distant soft tissue metastases. *CT* - **CT scans** (Computed Tomography) are excellent for assessing bone anatomy, cortical destruction, and soft tissue involvement, but they are generally less sensitive for detecting early or widespread **osseous metastatic disease** compared to a bone scan. - CT provides detailed anatomical information but may miss early **marrow involvement** that alters bone metabolism. *Intravenous venogram* - An **intravenous venogram** is an imaging technique used to visualize veins, primarily for detecting **thrombosis** or venous insufficiency. - It has no role in the detection of **bone metastases**, as it provides no information about bone structure or metabolic activity.
Question 8: Most common site of osteogenic sarcoma is:
- A. Tibia, lower end
- B. Femur, upper end
- C. Tibia, upper end
- D. Femur, lower end (Correct Answer)
Explanation: ***Femur, lower end*** - The **distal femur** is the most common site for osteogenic sarcoma, accounting for approximately **40% of all cases** [1]. - This region, along with the **proximal tibia**, are the most frequent locations for this primary bone tumor [1]. *Tibia, lower end* - While osteogenic sarcoma can occur in the **tibia**, the **proximal end** is more commonly affected than the distal end. - The distal tibia is a less frequent site compared to the distal femur or proximal tibia. *Femur, upper end* - The **proximal femur** is a recognized site for osteogenic sarcoma, but it is less common than the **distal femur**. - Tumors in the proximal femur account for a smaller percentage of overall osteosarcoma cases. *Tibia, upper end* - The **proximal tibia** is the **second most common site** for osteogenic sarcoma, frequently affected after the distal femur [1]. - However, the question asks for the *most* common site, which remains the distal femur.
Question 9: What is the most appropriate treatment for a soap bubble appearance at the lower end of the radius?
- A. Local excision
- B. Excision and bone grafting (Correct Answer)
- C. Amputation
- D. Radiotherapy
Explanation: ***Excision and bone grafting*** - A **soap bubble appearance** at the lower end of the radius is highly suggestive of a **giant cell tumor (GCT)**, which is locally aggressive and has a high recurrence rate after simple curettage. - **Excision of the tumor and filling the defect with bone graft** is the preferred treatment to reduce recurrence and maintain skeletal integrity. *Local excision* - While local excision might remove the visible tumor, **GCTs are known to recur frequently** (up to 50%) after intralesional treatments like simple curettage. - It does not adequately address microscopic extensions or the risk of **local aggressive behavior**. *Amputation* - **Amputation is an overly aggressive and unnecessary treatment** for a GCT, as it is a benign but locally aggressive tumor. - It would be considered only in rare cases of extensive soft tissue invasion or intractable recurrence, which is not implied by a "soap bubble appearance." *Radiotherapy* - **Radiotherapy is generally not the first-line treatment for GCTs** due to concerns about **malignant transformation** (osteosarcoma) in a small percentage of cases, especially with high doses. - It may be considered for unresectable tumors or recurrent lesions in difficult anatomical locations, or as an adjuvant.
Question 10: In the treatment of osteosarcoma, all of the following chemotherapy agents are used EXCEPT:
- A. High dose methotrexate
- B. Cyclophosphamide
- C. Vincristine (Correct Answer)
- D. Doxorubicin
Explanation: **Explanation:** The standard of care for **Osteosarcoma** involves a multimodal approach consisting of neoadjuvant chemotherapy, wide local surgical excision (limb-salvage surgery), and adjuvant chemotherapy. **Why Vincristine is the correct answer:** Vincristine is a vinca alkaloid that inhibits microtubule formation. While it is a cornerstone in the treatment of **Ewing’s Sarcoma** (as part of the VAC/VAI regimen), it has no proven efficacy against Osteosarcoma. Therefore, it is not included in standard osteosarcoma protocols. **Analysis of other options:** * **High-dose Methotrexate (with Leucovorin rescue):** This is a primary agent used to inhibit dihydrofolate reductase, crucial for treating high-grade osteosarcoma. * **Doxorubicin (Adriamycin):** An anthracycline that remains one of the most effective drugs for bone sarcomas. * **Cyclophosphamide:** While not part of the primary "MAP" (Methotrexate, Adriamycin, Platinum) regimen, it is frequently used in **second-line or salvage therapy** for recurrent or refractory osteosarcoma. **High-Yield NEET-PG Pearls:** 1. **Standard Regimen (MAP):** The most common chemotherapy combination for Osteosarcoma is **M**ethotrexate, **A**driamycin (Doxorubicin), and **P**latin (Cisplatin). 2. **Ewing’s Sarcoma Regimen:** Remember the mnemonic **VAC** (Vincristine, Adriamycin, Cyclophosphamide) or **VAI** (Ifosfamide instead of Cyclophosphamide). 3. **Prognostic Marker:** The most important prognostic factor in osteosarcoma is the **histologic response to neoadjuvant chemotherapy** (Huvos grade; >90% necrosis indicates a good prognosis). 4. **Radio-resistance:** Osteosarcoma is generally radio-resistant, making chemotherapy and surgery the mainstays of treatment.
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