Limb-sparing techniques

Limb-sparing techniques, also known as limb-saving or limb-salvage techniques, are performed in order to give patients an alternative to amputation. There are many different types of limb-sparing techniques, including arthrodesis, arthroplasty, alloprosthetic composite, endoprosthetic reconstruction, prosthetic implants, and rotationplasty.

Arthrodesis

Arthrodesis is defined as, "the surgical immobilization of a joint so that the bones grow solidly together."[1] Arthrodesis can relieve pain from arthritis and fractures. This is accomplished through the use of allografts and autografts. Allografts are done by creating bone grafts from a donor bone bank, while autografts are bone grafts from other bones in a patient's body. Synthetic bones and metal plates can also be inserted to abate the pain.

Arthroplasty

Arthroplasty is very similar to arthrodesis. It literally means "surgical repair of joint.' In the past, arthroplasty used tissue and removal of bone to relieve pain. Currently, joints are removed and replaced with prosthetic limbs. This alleviates pain, allows a greater range of motion, and improves walking ability, all of which strengthen muscles. Arthroplasty of the shoulder is one of the most common of these procedures, though it has only been widely used since 1955. Themistocles Gluck is thought to have created the first shoulder arthroplasty in the 1800s.[2] Since Gluck never published any results or notes on the procedure, Jules Emile Pean is credited with performing the first shoulder arthroplasty in 1893.[2]

Alloprosthetic composite

Alloprosthetic composites are a combination of multiple limb-sparing techniques. Allografts are used to replace the bone that has been "resected" using arthroplasty techniques. Prosthesis is then used to support and strengthen the allografts. Alloprosthetic composites are flexible in that surgeons can adapt the implants for any situation.[3]

Prosthetic implants

Prosthetic implants are used when sections of bone must be replaced and no further growth is expected. Implants are mostly made from metals but the possibility of using ceramic material has been discussed among surgeons. Prosthetics can be temporary or permanent. Temporary implants remain in place until the bone has healed and are then removed. The temporary implants take most of the burden off of the fracture, causing the bone to become less dense. This can lead to the re-fracturing of the bone after the implant is removed. The implants can also cause stress concentrations as a result of the material difference between the bone and the plate. With the permanent prostheses, a putty like substance is injected into the implant site to keep the body, mainly the immune system, from fighting off the implant. This substance can deteriorate bony tissue and cause serious bone problems for the patient. Prosthetic limbs have been used for many years. There is evidence that prosthetic limbs were made even back to Ancient Egypt.[4] Prosthetic limbs have been used ever since, though the materials have been updated from the early leather and wood to sturdy metals.

Rotationplasty

Rotationplasty, more commonly known as Van-Nes or Borggreve Rotation, is a limb-sparing medical procedure performed when a patient's leg is amputated at the knee. The ankle joint is then rotated 180 degrees and is attached to the former knee joint, becoming a new knee joint. This allows patients to have two fully functional feet, as opposed to losing one leg completely to amputation.

Reasons for rotationplasty

Originally, rotationplasty was performed to treat infections and tumors around the knee. It was also a common treatment for osteosarcoma.[5] While it is still being used to treat their complications, rotationplasty is also used to treat growing children who have been diagnosed with tumors around the knee.[6] Rotationplasty is also performed on children with congenital femoral deficiencies. Those deficiencies cause "unstable hip joint[s] and a femur that is 50% shorter than the contralateral, normal femur."[7] This procedure gives rotationplasty patients the ability to have the use of both feet and allows them to continue living an active lifestyle.

History of rotationplasty

Rotationplasty was first performed by Borggreve in 1927.[8] He performed the procedure on a 12-year-old boy who had tuberculosis. However, the procedure was not well known until 1950. At that time, physician Van Nes reported the results of rotationplasty procedures. He became well known for founding the procedure. Since then, many surgeons have performed modified versions of rotationplasty and have had great success.

Rotationplasty procedure

In the actual procedure, the bone affected by the tumor, as well as a small part of the healthy femoral and occasionally tibia bone, is removed. A portion of the leg removed; the ankle joint is then turned 180 degrees and is reattached to the thigh. They are held together by plates and screws until they have healed naturally. The surgery can take anywhere from 6 to 10 hours, with a day or two in intensive care.[6] The leg is kept in a cast for 6 to 12 weeks. After the leg has sufficiently healed, the leg can be fitted for a prosthetic.[8]

Advantages and disadvantages of rotationplasty

In the same scenario, amputation would not leave a knee joint. Rotationplasty allows the use of a knee joint. Furthermore, it provides a better position for a prosthetic limb. As a result, children who have had rotationplasty can play sports, run, climb, etc. Rotationplasty is also durable.[6] Patients do not typically have to undergo additional surgeries throughout their lives. Unfortunately, not every case turns out favorably. Rotationplasty can result in problems with blood supply to the leg, infection, nerve injuries, problems with bone healing, and fracture of the leg.[9]

Quality of life

German orthopedists Robert W Rödl, Ursula Pohlmann, Georg Gosheger, Norbert J Lindner, and Winfried Winkelmann evaluated a study that measured life contentment and quality of life in 22 patients who had been recipients of the rotationplasty procedure at least 10 years before. They found that those patients that were younger when the procedure was performed were happier with their lives. It was also found that 8 of the 22 had to have a total of 21 surgical revisions performed in the 10 years. In comparison to the general population, the patients had a higher percentage of quality of life, 83% compared to 75%. Overall, the patients were more content with different aspects of their lives than the general population.[10]

References
  1. "arthrodesis." Merriam-Webster.com. Merriam-Webster, 2011. Web. 2011. 19 October 2011.
  2. Flatow, Evan L., and Alicia K. Harrison. "A History of Reverse Total Shoulder Arthroplasty." Clinical Orthopaedics and Related Research 469.9 (2011): 2432–9. Print.
  3. Donati, Davide, et al. "Alloprosthetic Composite is a Suitable Reconstruction After Periacetabular Tumor Resection." Clinical Orthopaedics & Related Research 469.5 (2011): 1450–8. Print.
  4. Thurston, Alan J. "ParÉ and Prosthetics: The Early History of Artificial Limbs." ANZ Journal of Surgery 77.12 (2007): 1114–9. Print.
  5. Ramseier, Leonhard E., Charles E. Dumont, and G. Ulrich Exner. "Rotationplasty (Borggreve/Van Nes and Modifications) as an Alternative to Amputation in Failed Reconstructions After Resection of Tumours Around the Knee Joint." Scandinavian Journal of Plastic & Reconstructive Surgery & Hand Surgery 42.4 (2008): 199–201. Print.
  6. Soni, Emily. "A Surgeon's Approach – The Dynamics of Rotationplasty." Rotationplasty. N.p., 2011. Web. 19 Oct 2011. <http://www.rotationplasty.org/A-Surgeons-Approach--The-Dynamics-of-Rotationplasty>.
  7. Brown, Kenneth L. B. "Resection, Rotationplasty, and Femoropelvic Arthrodesis in Severe Congenital Femoral Deficiency." Journal of Bone and Joint Surgery, American Volume 83.1 (2001): 78. Print.
  8. Kotz, R. "Rotationplasty." Seminars in surgical oncology 13.1 (1997): 34–40. Print.
  9. Hillmann, A., et al. "Rotationplasty – Surgical Treatment Modality After Failed Limb Salvage Procedure." Archives of orthopaedic and trauma surgery 120.10 (2000): 555–8. Print.
  10. Rödl, Robert,W., et al. "Rotationplasty—quality of Life After 10 Years in 22 Patients." Acta Orthopaedica Scandinavica 73.1 (2002): 85–8. Print.
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