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Use of Spare Parts in Musculoskeletal Oncology


Introduction


Radical amputation of a limb following resection of huge bone and soft tissue sarcomas usually produces a defect necessitating a coverage procedure. There could be many choices for coverage. We are reporting two cases in which the post-amputation defects were covered using “Spare Parts”: as free myocutaneous flaps harvested from the amputated limb, distal to the primary tumor.

We report two cases in which bone and soft tissue sarcomas progressed to an extent where amputation was required. This can occur due to inappropriate primary surgery but more importantly, due to delayed presentation of tumor when the primary lesion is big and extra-compartmental. The huge defect left by the amputation necessitates a coverage procedure; this can be adequately provided by using spare parts, as free flaps from the amputated limb.

The harvest of free flaps from amputated extremities for use in reconstruction is a well described reconstructive and plastic surgical procedure. This technique has been reported for closure of large traumatic wounds and for coverage and closure following large amputations for oncologic purposes. Both myocutaneous and fascio-cutaneous varieties have been used.

Our experience of utilizing spare parts is being presented in the following two cases. The first is a maltreated case of osteogenic sarcoma affecting the head and neck of femur. The second case is that of a huge neglected primary Spindle cell sarcoma of the shoulder girdle.

Presentation


Case 1

This 40 year old male; presented to the clinic with pain in the left hip for one year.

All initial evaluation and surgeries were done outside our institution. Bone scan and X-ray were reported as Avascular Necrosis of the femoral head. CT scan revealed both radio-lucent and radio-opaque changes in the head and neck of femur ( Fig. 1a ).

He underwent core decompression/curettage with fibular grafting ( Fig. 1b ). Bone was sent for biopsy during core decompression reported Osteogenic sarcoma on histopathalogical basis. Based on this information the primary surgeon performed inter-lesional resection of the femoral head and replaced it with an Austin Moore prosthesis ( Fig. 1c ).

With time the tumor progressed to involve the acetabulum and the femoral shaft. As a consequence, the patient developed a pathological peri-prosthetic fracture in the proximal shat of left femur ( Fig. 1d ). In addition the incisions utilized for the above mentioned procedures ( Fig. 2a ) violated the anterior and posterior flaps of skin. On presentation to our clinic he was planned for MRI scan; to assess the local extent of the disease. The Austin Moore implant was thus, removed as the first phase of treatment ( Fig. 1e ).
The staging work up revealed a locally advanced non-metastatic disease which had not yet invaded the medial wall of the acetabulum.( Fig. 1f ).

Case 2

49 year old gentleman, presented to our clinic with right shoulder swelling and pain for the last one year.

History of the patient revealed; the mass arising as a small swelling on the right shoulder one year prior to the first presentation. Fine needle aspiration cytology was done and revealed atypical cells. No further intervention was done.
On presentation at our clinic the swelling had greatly increased in size ( Fig. 4a , Fig. 4b ). He was offered a forequarter amputation, but left without any decision.

He then presented to the clinic 4 months later with a proximal arm mass, much increased in size since prior presentation, it was now ulcerating at various points and was accompanied by purulent discharge ( Fig. 4c ). The distal neuro-vasculature was, however, intact.

Following the second presentation, staging workup was ordered. MRI revealed lesion of the right shoulder involving proximal humerus, Scapula, third rib, rotator cuff muscles, Serratus anterior, intercostals muscles in the second and third space ( Fig. 3a , Fig. 3b ). CT scan of the chest did not reveal any mets. Core biopsy revealed a malignant spindle cell sarcoma.

Management


Case 1

Considering the progression and extent of the disease an external hemipelvectomy was planned. No typical flap, anterior or posterior could be raised for closure as the previous incisions and the pathological fracture had contaminated both of them, so an incision as shown in ( Fig. 2b ) was made. Pelvic osteotomy was done just close to the sacro-illiac joint and the symphysis. A huge section of exposed bone and peritoneal fat ( Fig. 2c ) required coverage.

Before proceeding with the surgery a tourniquet was applied below the fracture on the thigh and the limb was disarticulated at the knee joint, use of spare parts from the amputated limb was employed in the form of a free myocutaneous flap of posterior calf skin supplied by the sural nerve, comprising of the Gastrocnemius and Soleus, based on the popliteal artery and vein was harvested. The free flap harvested from amputated leg was sutured into place and popliteal artery anastamosed with the internal iliac artery and the popliteal vein with the internal iliac vein. ( Fig. 2d ).

Post- surgery biopsy confirmed Osteogenic Sarcoma and Approximately 15-20% of the tumor showed necrosis and all the marrow resection and all marrow resection margins of the pubic and, iliac and ischial bones were tumor free. All nine inguinal lymph nodes from the inguinal region were negative for tumor.
He subsequently showed uneventful healing. The patient has had a two year follow-up with no evidence of reoccurence ( Fig. 2e ).

Case 2

Based on aforementioned the findings a right forequarter amputation with the excision of the third rib, rotator cuff muscles, Pectoralis major, Seratous anterior and intercostals muscles in the second and third intercostals space was done ( Fig. 4d ). Before amputating, the upper limb was disarticulated at the elbow under tourniquet control and a free myocutaneous flap from the forearm was harvested including skin from both the dorsal and volar aspects of the forearm as well as all the flexors of the forearm. This was done to increase the thickness and hence the viability of the flap. The flap taken was based on the brachial artery which was eventually anastamosed with the Subclavian artery and vein using end to side anastomosis to cover the defect created by fore-quarter amputation ( Fig. 4e ).

The skin and muscle margins were negative for tumor. Post operative course was marked by local infection which responded to IV antibiotics and progressed to complete healing. The patient has had close to two years of follow-up and there is no evidence of local disease ( Fig. 4f ). He did, however develop multiple small nodules in both lungs after a year and half of the index surgery for which he is currently receiving palliative chemotherapy.

Figures


Discussion


References




Corresponding Author

Noor Anjum
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