Dr. Himanshu Rohela: Limb Salvage Surgery

    Father of 8 year old boy (Name withheld) came to my outpatient clinic of orthopaedic oncology 3 weeks back. He had come after consulting many renowned hospitals in Mumbai and in other cities across India.  He was confused, dejected and in hope to save leg of his only child.

    On detailed history taking and scanning through the previous treatment records, I could reach to a conclusion that the boy was suffering from a cancer of left thigh bone (Ewing’s sarcoma of left femur).

    The worrisome thing in this particular case was fracture which had happened in the thigh bone of this child due to the cancer and presence of a metal implant used for fracture fixation. In such scenario it is technically demanding for any bone cancer surgeon to save the limb of the patient during the surgical treatment and most often the treatment which is offered to these patients is amputation surgery followed by chemotherapy.

    Traditionally some surgical alternatives are available in such situation where the limb could be saved, such as removing the thigh bone and replacing it with metal prosthesis or removing the thigh bone and re-implanting it after radiotherapy treatment of the removed bone (ECRT- extracorporeal radiotherapy) to kill cancer cells.

    If metal prosthesis is planned then there are multiple complications associated with this surgical procedure among them the most important is loosening of prosthesis with time amounting to high revision surgery rates. Secondly the child will have a short limb in future because the metal prosthesis will not grown in length with age and time as compared to other leg.

    ECRT treatment is a good surgical alternative for such patient where the growing ends of cancer affected bone are saved during removal of tumour bearing part of bone so that after re-implantation the limb continues to grow with age and time. On Treating with radiotherapy, the tumour cells are definitely killed but the bone cells also die and this bone does not unite easily to the remaining bone and almost always another bone with its intact blood supply taken from lower leg is implanted along with this bone it to promote healing and union. This added surgical procedure is time taking, technically demanding and sometimes even with all this due to certain reasons there is no union. It has been observed that with this surgical treatment the bone union occurs generally at 9-12 months after surgery and the child has to be in plaster and not bear weight on this limb for almost a year.

    On seeing the X-rays and MRI of this boy and after detailed discussion with our team of oncologists, I was able to provide a novel and innovative surgical treatment for this specific case. We decided to remove the tumour bearing bone while saving the growing ends of bone something similar to ECRT treatment but instead of radiotherapy treatment of removed bone we treated this bone with liquid nitrogen and re-implanted it with help of plate and screws.

    Recently, in the studies done outside India, Liquid nitrogen treatment of tumour bearing bone has been proven to kill the tumour cells preserving the osteo-induction capacity ( ability to induce bone healing process) of treated bone. This treated bone is not as strong as the original bone but it heals and unites faster almost in around 6-8 months without the help of any other additional bone support like used in ECRT.

    This innovative surgical technique need expertise and not many cancer centres in India provide this form of treatment to bone cancer patients.

    At Kokilaben Hospital we were successful in safely removing the tumour cells from the thigh bone of this young boy while preserving the growing potential of his thigh bone and salvaging his limb.  In Maharashtra, Kokilaben Dhirubhai Ambani Hospital is the first and only hospital in private sector to provide these services for bone cancer patients.