FM AUGUST 2018 ISSUE1 - digital edition

The primary treatment strategy in most patients includes
reconstructive surgery where the tumour is resected, and the
bone defect replaced by bone allografts or metal plates. This
procedure involves complex surgical techniques that are primarily
designed to save the limb, and hence is aptly termed ’limb
salvage surgery’. While about 80% of those diagnosed with
these tumours can be treated with the limb salvage surgery,
unfortunately, when the tumour is located in anatomical locations
where it cannot be accessed or when the tumour is big and
recurrent, limb saving may not be a plausible option, and the
amputation of the limb becomes an inevitable.
implant for the reconstructive surgery, and the MDT team
acquired fresh frozen allograft of the elbow from collaborators
in Italy. Considering the location of the tumour, the surgery to
be performed was quite delicate. However, all the nerves and
arteries were carefully dissected and salvaged. The bone was
cut, the tumour resected, and the area was reconstructed with
the allograft prosthetic composite and the fresh frozen allograft.
The patient tolerated the surgery well, and today, after one and
a half years, the patient is disease-free and has a fully functional
hand allowing for normal daily activities, and is on her way to
treat patients herself.
Here is the case of a young medical student diagnosed with
osteosarcoma of the right elbow, an extremely rare site for
such tumours. The patient was told by multiple oncology
surgeons across the country that her only option was to
undergo an above-the-elbow amputation. At her age and time
in life, an amputated limb would
most definitely have halted her
blossoming medical career and
perhaps shattered her professional
dreams and aspirations.
After several physician visits and
consultations, she was eventually
referred to HealthCare Global
Enterprises Ltd. (HCG) and
evaluated by their multi–disciplinary
team (MDT) with the standard
investigative tests including X-Ray,
3D Local MRI, and whole-body PET
CT scan. She was diagnosed with
an aggressive, non-metastatic,
malignant, intermediate grade
tumour of the ulna. With limb
salvage surgery as the goal, she was started on a neo-adjuvant
chemotherapy with a high dose methotrexate regimen. However,
this treatment resulted in a moderate clinical response, with
the tumour size decreasing only marginally. Considering the
size of the tumour, the location and the complexity of the
reconstructive surgery, questions were again raised whether it
was feasible to save her limb. However, after discussions with
the patient and her family, the MDT decided to go ahead with
limb salvage surgery. Additionally, it also helped that the patient,
with her medical background and understanding, was able to
fully comprehend the situation and take an informed judgement
call on her treatment plan.
Allograft prosthetic composite was the primary choice of
At her age and time in life,
an amputated limb would
most definitely have halted
her blossoming medical
career and perhaps shattered
her professional dreams
and aspirations
In this relatively new, niche field of orthopedic oncology in
India, several factors play a role in determining the treatment
option. First, the facilities and technological expertise that the
doctors can provide is a fundamental factor in the decision
making for treatment options. The absence of a bone bank
in India hinders the availability
of bone allografts. However, for
successful treatment options, it is
a requirement for any orthopaedic
oncology department and a good
organ donation programme would
considerably help in maintaining such
a bone bank. Second, the location of
the tumour also plays an important
role in deciding the outcome. Typically,
if the reconstructive surgery is too
complicated due to the location,
or the tumour is recurrent or large,
the natural treatment choice is
amputation. Surgeries need to be
well planned and complications need
to be considered. Tumour recurrence,
infection, prosthesis loosening,
restricted range of motion, and limb shortness are some of
the major complications observed. Recent advances in imaging,
allograft retrieval, as well as custom implant designing have led
the path to dramatic improvements in the surgical outcomes.
Long term chemotherapy and radiation may also be necessary
to manage outcomes.
Awareness of technological advances is important for the medical
community. What may have been considered impossible a few
years ago may be possible today. As seen in this case, limb salvage
surgeries are not impossible, even for rare and difficult sites such
as the elbow, it is possible to have successful outcomes where
the patient continues to be able to perform daily activities.
- Dr Shivanee Shah
AUGUST 2018/ FUTURE MEDICINE / 67