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Expert Speak

Saving the Limbs of Bone Cancer Patients

By Dr Mayil Vahanan Natarajan

In the last 14 years, Dr Mayil Vahanan Natarajan, a renowned orthopaedic surgeon, has helped six hundred bone cancer patients avoid amputation. He has pioneered Limb Salvage Surgery, where the affected part of the bone is removed without cutting off the whole limb, in India. He has also been involved in the local production of custom made prostheses at a fraction of the cost of imported implants, so that this treatment is affordable to a larger section of the Indian population. Recently he published his research report on this type of surgery.

Here Dr Mayil Vahanan Natarajan discusses the highlights of limb sparing surgery.

What is limb salvage surgery?

When a person has cancer of the bone, surgery forms a part of the treatment. Formerly, if the malignant tumour was in the limbs, surgery meant amputation of the limb. The entire arm or leg would be removed. This led to marked disability and disfigurement. The person also had to suffer social stigma. In order to overcome the functional, psychological and social problems associated with amputation, the concept of limb salvage was evolved.Here, despite the surgery and removal of the tumour, the limb is spared.

The aim of limb salvage surgery in bone tumour management is to eradicate the disease, retain the integrity of the skeletal system and preserve a limb with useful function.

What are the processes involved in this kind of surgery?

Successful limb sparing procedures consists of 3 phases namely,

  1. Bone resection: After making an accurate assessment of the stage and spread of the tumour the surgeon removes the affected part of the bone.
  2. Reconstruction: The second phase of the procedure involves replacing the missing part of the bone with a graft or an implant (prosthesis). Bone can be grafted from some other part of the patient’s body. Prostheses or implants are made of steel or titanium.
  3. Plastic surgery: This is performed to cover the area with muscle and soft tissues.

Are the prosthesis (fabricated parts that replace the removed part of the bone) readily available?

There are two types of “mega” prosthesis: custom made or modular. Custom made prostheses are individually manufactured for each patient and give an accurate fit. However, they have to be ordered, made, delivered and delays may occur. Modular systems are always available and allow variable resection according to their multi component design. Here, the problem is, “the patient is required to fit the prosthesis.”

If good quality custom made prostheses are quickly and easily available, these are definitely to be recommended over modular prosthesis.

Are bone replacing implants specifically manufactured to suit each patient (custom made prosthesis) available in India? How much will they cost?

Normally, they are imported.

I have been involved in the use of locally (custom) made mega prostheses in Chennai for the past 14 years. Today, mega prostheses are available for all major anatomic regions of the body. Once a patient comes to us we take accurate measurements and request our fabricator to make a suitable prosthesis. It takes a couple of weeks to make the prosthesis.

The cost difference between the locally made prostheses and the imported ones has made a real impact on osteosarcoma patients in our country. The imported prosthesis can cost up to Rs 3, 50,000 ( US$ 8,000). The local product, made from stainless steel, costs only Rs 35, 000. We have also offered prostheses free for some poor patients in General Hospital, Chennai.

Will the patient be able to use the limb as before after this operation?

When a surgeon performs this operation for a bone cancer patient, his priorities are very clear: First, he has to prolong the life of the patient. His focus will be on accurately diagnosing the spread of the disease and removing the tumour. Then he focuses on saving the limb by using implants and grafts. Here he has to ask himself this question:

Will using a prosthesis be more advantageous to a patient than amputation of the entire limb and having an artificial limb?

That is, a prosthesis is fitted only when the surgeon feels:

  • The disease can be controlled by removing only one portion of the bone and not the whole limb
  • Using an implant will give the person more comfort than removing the hand or leg and fitting him with an artificial limb.

A patient may or may not be able to get the full use of the limb. But surely a certain amount of functionality will be restored. The main advantage will be that the cancer is being treated without major disfigurement, and the maximum possible functionality is being restored under the circumstances.

What is the age group of patients with bone cancer? Can you perform limb salvage surgery on all these patients?

Patients’ age range is from 17 – 70. Age is one of the factors we have to consider, as this is a major surgery and requires some rehabilitation effort on the patient’s part. Besides, aged patients may also have other risk factors such as heart disease, diabetes, prolonged chemotherapy and pre-existing infections.

If the patient is not very old, and his health does not have other complications, limb salvage surgery can be performed.

In very young patients who are still growing in height, the operated limb used to remain shorter than the other limb. Now, however, we have expandable prostheses that can be lengthened according to the growth of the limb.

What is the success rate of limb salvage surgery?

In my experience the results have been good. About 70% of the patients have greatly benefited from the surgery.

A fifteen year old girl was brought to me with a tumour in the upper left thigh. The swelling was increasing and the patient had been advised amputation in her consultation elsewhere. I performed limb salvage surgery in 1990 and in the three year follow up period the patient was walking well. Much of the hip movement had been restored. Today, after 16 years the patient is doing well.

A small number of patients have suffered some complications.

Some of the complications have resulted from oncological problems, where the cancer had recurred. Some from biological problems, where the patient was immuno-compromised and had infections etc. and in some of the patients the complication has been mechanical failure.

But it is important to note that these complications are possible even if the patient has had amputation instead of limb salvage surgery.

Nobody can guarantee that oncological problems or biological problems will not recur in bone cancer patients, even if the whole limb is amputated. Mechanical problems can occur in artificial limbs also.

What is your next goal in aiding bone cancer patients?

Limb salvage surgery is reaching new heights with total replacements of the thigh bone, hip and knee joints. These will give hope to a greater number of bone cancer patients.

Secondly, we can improve the type of prostheses that are customised. Using titanium alloy instead of the stainless steel, which is being used at present, will make the prosthesis lighter and stronger.

I have spent many years on this work. My work has been based on my belief to Think Globally and Act Locally. I am keen to continue this work using titanium alloy to make good, affordable prosthesis for the greater benefit of patients in our country. As I am attached to the Government General Hospital, Chennai, I would like to prove that quality work is being done and can be done in public hospitals. As the Ministry of Defence, Govt. of India, is the sole source for titanium in our country, I hope the concerned departments of the government will see the value of this project.

Dr Mayil Vahanan Natarajan MBBS, D Orth ( Ma’s), M Ch Trauma Orth ( Liverpool) Ph D ( Orth Onco) is the Orthopaedic surgeon at the Government General Hospital (Chennai) and The Regional Cancer Institute( Chennai), a visiting consultant at Apollo Cancer and Specialities Hospital,Chennai. He is a scientist belonging to the State Council for Science and Technology, Tamil Nadu. He is the President of the Asia Pacific Musculo Skeletal Tumour Society. A Chennai based surgeon, his contribution to orthopaedics has been laudable. His work in orthopaedic oncology has been hailed as pioneering by doctors in India and abroad. He maintains a site for orthopaedic oncology enthusiasts called www.bonetumour.org.

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