No surgical procedure is easy. Especially if the organ is treated surgically that had attacked the tumor and is in the metastasis stage. However complex the challenge may be, the task is always the same: not to harm the patient, to perform the surgery in the best possible way, and to improve the patient’s quality of life afterwards.
These professional challenges are something that the experts working at Atlas General Hospital face almost daily. Dr. Aleksandar Djordjevic, an orthopedic specialist – oncologist, is one of the experts at Atlas Hospital. We had the opportunity to follow an operating procedure performed by Dr Aleksandar Djordjevic and his associates.
The specificity of this case is that the patient has already been treated for colon cancer and now the tumor has appeared in the area of the lower leg.
Lower leg tumor bone metastases
Dr Aleksandar Đorđević: “ The patient has already been treated with chemo therapy. So far everything has been in order. The patient was without any signs of the disease, however, a few months ago, pain in the lower leg appeared. Often, we don’t immediately think of a tumor. Unfortunately, there was a fracture and after that we have done an X ray, suspecting that it was a secondary deposit. Patient had performed an MRI to confirm our predictions. We also did supplemental diagnostics, we call it staging. Why it matters? Most metastases are inoperable, as they are already advanced disease, so these metastases are treated in palliative way, with radiation, with bone cancer pain drugs. On other organs it is by chemotherapy. However, in this case, we found no other signs of the disease, but the only place detectable in the body was the lower leg “.
When something like that happens, explains Dr. Djordjevic, treatment of the disease is approached as if it were the primary treatment.
Can we cure a tumor on the tibia?
Dr Aleksandar Đorđević: “We think we can cure a patient. There is one reason for it to be oncological, and the other reason is functional, since with a broken leg on which a malignant tumor has developed, the patient can no longer walk. The patient is in good general condition but we cannot predict how long his life will last. His life can take months, and it can take years. Functionality should be enabled for such a patient”.
We wanted to know more about the procedure itself. Such procedures are not routine in private hospitals, they are complex, but at Atlas General Hospital, like many other operations, they are successfully performed.
Are such complicated surgical methods (as lower leg tumor) performed in private hospitals?
Dr Aleksandar Đorđević:“ Such operations are the exclusivity of special oncology institutions. Our goal is to make Atlas Hospital a reference oncology facility. It is our common goal, not just mine, of course, but the whole team of doctors who work here. There are a large number of oncologists, many surgeons of various specialties, as well as a top anesthetic team. It is not typical for a private institution to perform such mutilating operations.
Unfortunately, private institutions are mainly concerned with diagnostics, and even when dealing with surgery, surgery is generally less invasive. We are going for the most aggressive type of surgery here, not just me but all the other colleagues involved in surgery. This is an interesting case because of course it is as complex in diagnostic indicative terms as it is in surgical planning. For such an operation, it is necessary for us to make an adequate reconstructive replacement, which is a custom-made metal prosthesis. So it works uniquely for that patient “.
By analyzing the MRI just before the operation of the tibia, or the bone of the lower leg, Dr Djordjevic revealed to us what it would look like, the sequence of actions to be done and the final goal that is to be achieved.
Replacement procedure of the tibia bone with prosthesis
Dr Aleksandar Đorđević: “Here you see, this is bone, and all around it are the soft tissue components of the expanding tumor. These are the major blood vessels here. We must preserve the main nerve, the tibialis and the main artery, the vein, in order to preserve the extremity itself. What is also important is to have a resection where the tissue is healthy. This is all a tumor, we have to go from healthy to healthy.
That’s what we mentioned – preoperative planning. After that we have another tibia specific issue. A patellar ligament is attached to the tibia, this is the patella – the calyx. It attaches via this ligament for the tibia, here you see. Since we have to take it all off and we have to preserve function, then we take one muscle of the gastrocnemius. We move the gastrocnemius forward and reinsert this ligament to preserve knee function. ”
This is the only way to reconstruct the extensor apparatus or return the mechanism to the knee, but the prosthesis should not be covered solely by the skin, the doctor points out, since the slightest healing in the lower leg can lead to infection.
Why infections in orthopedics are so dangerous
Dr Aleksandar Đorđević:“If an infection happens, the tissue can no longer heal. Infection is an orthopedic problem for us, especially when we have implants, a practically insoluble issue. So, the reconstruction must be in addition to the bone reconstruction and the musculoskeletal or muscular functional reconstruction. It is not a matter of getting a nice X-ray, but of having a function and not only having it, but also the long lasting function. There are other ways to rebuild, but this one has proven to be the most durable. This is what I emphasize – oncologic surgery cannot succeed unless you have a good oncological result and a good functional result. The patient expects to live a quality life, he is not interested in just one thing. The question of the patient is not only how much he can survive but also how he will live. ”
Living with advanced malignancy is not only a burden for the patient, but for the entire family, as well as the state’s health system. An alternative in metastatic skeletal pathology is very often just surgery.
Is the number of malignancies increasing in Serbia?
Dr Aleksandar Đorđević: “ The global trend is that there are more and more malignancies, unfortunately also in our country. We don’t have very clear information, it’s talked about, but in layman’ terms. We note, as clinicians, that there is indeed an increase in the rise of increasingly bizarre forms of malignancy. Patients are getting younger and what is interesting is that younger people are naturally functionally, socially, family and professionally active, and this is what matters “.
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