Major ablative procedures in orthopaedic surgery

In the presence of the notable progress in limb-sparing techniques afforded by the developments in microsurgery and musculoskeletal oncology, major ablative surgery of the extremities still remains a last-resort, yet powerful tool in managing patients with primary tumors in whom wide excision is not possible, as well as in cases with severe trauma to the limbs. During the last thirteen years, eight major ablative procedures were performed at the Department of Orthopaedic Surgery of the University of Ioannina Medical School. Seven out of the eight procedures were performed in patients with primary malignant tumors either because the anatomical location or multiple recurrences of the tumor did not allow removal by wide local excision or by amputation at a lower level. In one patient, the procedure was related to a severe, mangling trauma. Four illustrative cases of the eight major ablative procedures performed are reported to highlight the current indications of this rarely used, complex, and extensive surgery. The characteristic cases presented are: hemipelvectomy in a patient with chondrosarcoma of the pelvis, disarticulation of the hip in a patient with a malignant histiocytoma of the supracondylar area of the knee, forequarter amputation in a patient with a basal cell carcinoma of the axilla, and disarticulation of the shoulder in a patient with an incomplete nonviable amputation at the level of the shoulder girdle associated with severe damage to the brachial plexus and axillary artery. After a five to over a ten year follow-up, six of the eight patients who where subjected to major ablative procedures are doing well and are satisfactorily active. These cases reflect the dilemma that orthopaedic surgeons still face in selecting limb salvage or major ablative surgery in cases of aggressive malignant tumors or severe trauma.