Subspecialty Section: Amputation in the context of tumour or infection

Amputation in the context of tumour or infection

Martina Faimali and Will Aston

Martina Faimali is a Senior Orthopaedic Registrar on the Stanmore rotation. She is passionate about the care of neck of femur patients with a particular interest in infection, revision and fragility work.

Will Aston is a Consultant Orthopaedic Surgeon at the Royal National Orthopaedic Hospital, Stanmore. Will specialises in hip and knee surgery including the management of bone and soft tissue tumours. His research interests include the design and fixation of massive prostheses in limb salvage surgery and the use of these techniques in revision joint replacement surgery. Initially fraught with complications including death from sepsis or haemorrhage, amputation has evolved from a procedure performed as rapidly as possible, to a definitive carefully planned and executed treatment option1. Despite advances in surgical and medical care, in the context of tumour or periprosthetic joint infection, amputation rates remain high. This review aims to discuss some of the considerations and philosophy behind the decision-making process, providing a guide to the management of such cases.

Periprosthetic joint infection patient5. Medically unwell patients are more likely to die or require an amputation, whilst Periprosthetic joint infections (PJIs) are a healthier patients may undergo attempts at devastating consequence of arthroplasty, eradicating the infection. There is a strong associated with significant morbidity and correlation between poor, compromised mortality. Infection local tissues and is present in over the need for plastic 25% of revision cases; a figure that “Medically unwell patients surgical intervention with a flap and/or will increase with an are more likely to die or soft tissue transfer or ageing population with greater rates of require an amputation, recommendation of a primary amputation. diabetes, obesity and other comorbidities2 . whilst healthier patients In the context of lifethreatening sepsis, Access to joint may undergo attempts at an amputation may be arthroplasty continues to rise and eradicating the infection.” the only option6 . A more likely it is predicted that scenario however is the annual rate of the multiply revised, PJI in the US could be between 38-270,000 chronically infected patient where further by 20303,4. Sadly amputation will remain an revision procedures are not indicated. In our endpoint for some patients. experience the indication for an amputation includes massive bone loss, extensive soft We advocate the concept introduced by tissue involvement, persistent and resistant McPherson et al. which considers local factors infection despite attempts at control as well as as well as the general medical status of the patient factors. Multiply drug resistant >>

and fungal species are particularly difficult to eradicate and long-term suppressive antibiotics (and their side effects) may not be suitable or acceptable to the patient. Previous studies have indicated an increased prevalence of above knee amputation (AKA) following an infected total knee replacement (TKR) in certain patient populations. These include male sex, black race, lower socioeconomic class, aged over 80 or younger than 50 and increasing numbers of comorbidities7. The associations were based on case series yet given the poor functional outcomes associated with AKA, it is essential to risk stratify patients before considering surgery so that they can be appropriately counselled regarding their risks7. This is particularly important given the higher energy expenditure necessary to mobilise following an AKA. In one series of 25 AKA patients (19 for failed PJI management), only 30% were walking regularly and 52% were wheelchair dependent8. If an amputation is considered the MDT approach allows the physical and psychological needs of the patient to be met and managed appropriately.

Tumour and amputation

Primary bone and soft tissue tumours are rare and require specialist care. In the UK they are primarily managed in five specialist sarcoma units, with adjunctive treatments

b.

d. a. b. c.

Figure 2: 37 year old Male, Ewing’s sarcoma of the distal fibula. Coronal (a) and sagittal (b) MRI scans highlight the extensive involvement, and AP radiograph (c) of the below knee amputation required to achieve a wide margin for the tumour resection.

(chemotherapy and radiotherapy) delivered at a local level. Primary malignant bone tumours comprise 0.2% of all cancers diagnosed in England annually, hence a GP may only see one such patient in their whole career9. Improved survival and less radical surgery are related to timely investigations and management yet delays in diagnosis are sadly still common10 . Despite their rarity, 5% of childhood cancers in Europe are primary malignant bone tumours11. In adults primary malignancies are vastly outnumbered by metastatic disease and haemopoietic malignancies. Despite oncological and surgical advances five-year survival rates for patients with primary bone sarcomas remain static around 53-55%9 .

In comparison soft tissue sarcomas are more common, occurring at any age although most commonly in middle-older age groups. They comprise 7-10% of all childhood cancers and are an important cause of death in the 14-29 year old age group9,12,13. Of those with an intermediate or high grade tumour approximately 50% will develop metastatic disease and require systemic treatment14 . Survival rates are similar to those of primary bone tumours (55% at five years)15 .

If a primary bone or soft tissue malignancy is suspected, prompt referral to a specialist centre is advised. Surgery is the standard treatment for all patients with primary bone and soft tissue malignancies and should be performed by a surgeon with the appropriate training and experience in sarcoma management. The multidisciplinary team (MDT) will decide if the lesion is resectable taking into account factors which include tumour stage and grade, anatomical location, neurovascular involvement and co-morbidities. The principle aim is to excise the tumour with a margin of normal tissue outside the reactive zone. The size of this margin is debated but 1cm soft tissue envelope is commonly accepted. A functional limb is a secondary goal and may not always be possible due to anatomical constraints, poor response to treatment or the degree of resection necessary. In such cases, amputation may be a more appropriate procedure, (Figures 1 & 2).

Figure 1: 74 year old male, dedifferentiated chondrosarcoma of proximal femur. AP radiograph (a), coronal (b) and sagittal (c) MRI scans highlight the large soft tissue mass and bone involvement, and the postop film (d) following a hindquarter amputation for tumour clearance. In patients with a poor response to chemotherapy (>90% histological necrosis following chemotherapy represents a good treatment response) and ‘close’ bony margins there is currently insufficient evidence to support improved outcomes with amputation, as opposed to primary limb salvage with the possible increased rate of local recurrence9 .

With recurrence, all patients should be staged carefully since metastatic disease is common. Attempts should be made to regain local control through surgery and adjunctive treatment but for some this may mean an amputation based upon what function remains following repeated surgery, their performance status and of course their wishes, (Figure 3).

A more common scenario is metastatic disease from another tumour (estimated lifetime risk of being diagnosed with cancer is 1 in 2)16. Those presenting with impending or pathological fractures are not uncommon and decisions regarding treatment are often dependent on whether systemic therapy is an option. Important considerations include whether the disease is curable or not, the life expectancy of the patient and their degree of symptoms. Surgery is undertaken to improve quality of life, and an amputation in some circumstances is recommended as a palliative procedure if reconstructive options are not appropriate, or there is fungating disease.

Difficult decisions arise in the presence of a primary bone tumour with a pathological fracture. Due to the contamination of the surrounding soft tissues (as a result of the fracture) a primary amputation may be the recommended option in the absence of metastatic disease, particularly in high grade tumours that are not responsive to adjuvant treatment such as a chondrosarcoma.

a. b.

The multidisciplinary team approach Early involvement of the rehabilitation team This is a vital part of the decision-making and their care should be sought as early process in amputation, enabling an informed as possible. Psychological concerns for decision for both clinicians and patients. Each amputees include loss of confidence, the institution may distress of metastatic not have access disease, fear of the to all necessary unknown and loss resources, “Psychological concerns of independence21 . thus we would recommend for amputees include loss This can contribute to a risk of suicide in referral to a of confidence, the distress the post-operative regional MDT to help with of metastatic disease, fear period21 . management decisions. of the unknown and loss of independence. This can Philosophy of the amputation With PJI or malignancy, contribute to a risk of suicide When planning an amputation with significant in the post-operative period.” for infection or co-morbidities, tumour there amputation are a number of rather than factors to consider revision or limb salvage may be recommended including the ideal stump length to enable to minimise the risk to the patient. Similarly, prosthetic fitting, the ability to achieve due to the condition of the soft tissues, a wide local excision and a satisfactory an amputation may be favoured. To our wound closure and weight bearing stump. knowledge no study has evaluated MDT is essential when considering an amputation, interventions in a randomised manner, The concept of a wide local excision is however there is a wealth of literature in common with malignant or aggressive the infection setting supporting their role, benign tumours, with the aim to reduce with excellent results reflected in fewer local recurrence. The same thought operations, reduced length of stay and process should apply with PJI’s, with the reduced antibiotic requirement17-20 . amputation performed without entering the pseudocapsule of the joint or encountering pockets of infection. In some locations, such as a below knee amputation for an infection ankle prosthesis, this is readily achievable. With an infected stemmed knee replacement, the level of the bone transection should be above the implant or cement mantle to achieve clearance of infection. With an infected hip or proximal femoral replacement this is more challenging. Leaving an intact pelvic ring facilitates sitting, however in some instances a higher amputation may be required if the soft tissues are poor or the aggressiveness of the organism dictates this.

Figure 3: Plain radiograph (a) and coronal MRI (b) showing metastatic angiosarcoma around the cemented femoral stem of a tumour prosthesis. A hip disarticulation was required.

Conclusion

Amputation is a safe and reliable treatment option for patients with malignancies or failed treatment of PJI’s. The perioperative risks are low and adequate margins can be achieved. Support and management by the MDT are vital and the patient counselled throughout the process regarding their options. Important considerations include the primary goal of treatment, associated co-morbidities and the patient’s wishes. n

References

References can be found online at www.boa.ac.uk/publications/JTO.

John Ireland 14 July 1942 – 16 May 2019

Obituary by By David Ireland & Richard Parkinson

John Ireland was one of the leading knee surgeons of his era. His long-lasting care for his patients inspired affection and loyalty and a large number of amateur and professional sportsmen have been able to resume their sport at the highest level after his surgical interventions. He was also a founder member of the British Association for Surgery of the Knee (BASK). John trained in medicine at Westminster Hospital Medical School and from his early days displayed an adventurous spirit and a desire to learn. He did his student elective in France and returned to England with valuable surgical experience and with the ability to speak good French. On qualifying, he served as ship’s surgeon aboard the Canberra en route to a post as general surgeon to a hospital in Papua New Guinea. He met his future wife Shahla while working as a registrar at Hillingdon Hospital. He trained at RNOH, and it was working on the knee, especially for the late Lorden Trickey, that he found his particular interest. After many years as a consultant at King George’s in Essex, he left the NHS when commitments to support a knee unit were not honoured. Thereafter, he worked in private practice, securing funding for a Knee Fellow at Holly House hospital, with an orthopaedic registrar rotation between Holly House and Newham in the NHS. Aside from work and family life, golf was his life’s passion. He played whenever he could and set up the New Knee Golf Society for players of golf of any standard who had undergone knee replacement surgery. His characteristic handwriting reflected the man – bold and distinctive, yet at the same time, careful and precise. His love of chamber music was also a constant throughout his life. Generous and tireless in helping others, John will be long remembered in the orthopaedic community for his surgical expertise, his distinctive style, his passion for golf, and his kindness. He bore his final illness with grace and courage. He leaves his wife Shahla, two sons and a daughter. He is survived by his first wife Eileen, and their son and three daughters, two of whom are doctors, and his second wife Margaret. n

Kyle Martin McDonald 26 July 2020

Obituary by Sam Sloan

It is with great sadness that we announce the sudden death of our esteemed colleague and friend Kyle McDonald. Kyle was an exceptional Spinal surgeon who will be missed by patients and colleagues alike. He was a loving husband to Poppy and devoted father of Darcey and Rory. Kyle graduated from Queen’s University medical school and completed his orthopaedic training in Northern Ireland whilst gaining the Sir Walter Mercer Medal for the highest marks in the exit exam. Upon completion of his training he embarked upon a fellowship in Scoliosis surgery in Dublin before returning as a Consultant in 2017. This level of achievement summed up Kyle perfectly. He was a supremely gifted and talented surgeon who made the hard things look easy. Patients and staff due to his carefree nature and quick wit loved Kyle. His sense of humour was unrivalled. He was a kind person who devoted his time to caring for his Scoliosis patients. Nothing was too much trouble for him. Above all Kyle cherished his beautiful family. He valued the time he spent with his fantastic wife and darling children. At this time we offer our deepest sympathies and love to Poppy, Darcey, Rory and the wider McDonald family. Our team will never forget what Kyle brought to us. We are weaker as a result. The UK spinal community has lost a young and talented surgeon, who had given so much and who could have given so much more. Sadly Kyle was taken from us too soon but his legacy will be with us forever. Rest in peace. n