الفهرس 
Principles of limb salvageOnly 14 pages are availabe for public view
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Abstract
Summary
Recently, the development of the chemotherapeutic agents has encouraged limb salvage in cases of malignant bone tumors. However, limb salvage has some prerequisites to be done; otherwise, amputation became the favorable option for treatment. There are several techniques for limb salvage either no surgery, resection only or resection and reconstruction. Various forms of reconstruction are available. Biological reconstruction involves the use of autografts, allografts or distraction osteogenesis. Endoprosthetic reconstruction includes conventional endoprosthetic replacement, allograft-prosthetic complex, or expandable prosthesis. Recycling could also be done by freezing, extracorporeal-irradiation, or heating by autoclaving or pasteurization. Furthermore, soft tissue reconstruction is important and should be considered in different ways according to the anatomical region involved.
Treatment using circular fixators has evolved in the last years to solve the problems of limb reconstruction in cases of benign or malignant tumors. Ilizarov fixator could be used in various forms in the management of bone tumors. Firstly, primary reconstruction through lengthening or bone transport following resection of malignant bone tumors could be done. Secondly, it could be used for lengthening and/or deformity correction in benign bone tumors. Thirdly, it could be used as an external fixator of a graft for the bone defect in cases where internal fixation was contraindicated. Fourthly, it would be crucial in the management of some cases of bone tumors where primary management has failed.
Summary
192
As any treatment option, there are pros and cons for the use of circular fixators in the management of bone tumors. The pros are that it is not restricted to a particular age, it is versatile so its pattern of use could be modified according to patient needs, it is mechanically stable, weight bearing is possible, it is dynamic, it allows segmental compression, it promotes limb lengthening and gradual deformity correction, it is biological, it combats infection and, lastly, it might be the last resort in case of failure of other methods of limb reconstruction. On the other hand, the cons are pin tract infections, muscle contractures, neurovascular complications, joint subluxation, fracture regenerate, prolonged treatment, joint stiffness, or psychological stress. There are many methods used in the classification of adverse events, which result from the use of circular fixators. The most acceptable one is the Paley’s classification into problems, obstacles and complications.
We have conducted this study at the department of orthopedic surgery in Ain Shams University hospitals. The study was done on 15 patients with benign or malignant tumors, who were treated by resection followed by bone and soft tissue reconstruction and Ilizarov circular fixator during January 2012-April 2013 and followed up till July 2014. The mean age of the patient was 21.1(7-52) years old. The patients were 9 male and 6 female. They present with different pictures; the most common was pain and swelling. 7 cases were benign and 8 cases were malignant. The most common pathology was osteosarcoma (5 cases). The most common anatomical site was the distal tibia (4 cases). 7 patients only underwent previous surgeries.
Summary
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Full history and clinical examination was done for all patients. After deciding a provisional diagnosis, investigations are done to discover the final diagnosis. Neoadjuvant chemotherapy was given to osteosarcoma cases followed by clinical and radiological reassessment. Surgery was done to resect or excise the tumor, skeletal and soft tissue reconstruction, and Ilizarov circular fixator. Postoperatively, histopathological examination of the resected tumor was done to confirm the preoperative diagnosis, adjuvant chemotherapy was done if needed, antibiotics were given, and regular outpatient follow-up was done with a mean period of 22.4 (14-28) months. In the office, assessment of the outcome as regards the tumor and the circular fixator was done using the MSTS score for all cases and the ASAMI-bone and ASAMI-function scores for lower limb cases. Moreover, adjustment of the frame was done as required.
As regards malignant tumors, the disease free survival has a mean of 22.4 (14-28) months. 2 patients developed local recurrence. 1 patient died as a result of chemotherapy. As regards all cases, the MSTS score was 50% to 100% with a mean value of 83.5%. As regards the lower limb cases, the ASAMI-bone score was excellent in 7 cases, good in 1 cases, and poor in 4 cases. The ASAMI-function score was excellent in 5 cases, good in 4 cases, poor in 1 case and failure in 2 cases. The adverse effects in our study were 6 problems, 5 obstacles and 9 complications according to Paley’s classification. The most common adverse event was pin tract infection, which was more severe in patients receiving chemotherapy (osteosarcoma cases).
Summary
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Our conclusion is that biological reconstruction using Ilizarov circular fixator should be considered safe and effective in the management of benign and malignant tumors, and a salvage treatment in case of failure of other methods of limb salvage.