Fortunately, few patients had exhausted both upper and lower limb options and only two patients were dialysing via a lumbar line (3a = 2).
For example, a patient dialysing through a complex upper limb graft may have no lower limb options due to arterial disease and thus could progress from Group 1 to Group 3 exhausted VA upon loss of graft patency.
> Within those classified as Category 2 (including those where upper limb options are exhausted since the classification is hierarchical), the majority of reasons were for vascular insufficiency (n = 16).
We have devised a systematic hierarchical classification of VA failure which is based on the concept that leg options are generally considered only when simple and complex upper limb options are not possible and that direct central venous cannulation options, for example translumbar CVC, are reserved for the most desperate.
This follows a simple sequential broad categorization: No upper limb VA option No Lower limb VA option No options at any site These can be further subdivided into the site of occlusion/stenosis.
The use of autoclaved tumor grafts provides a limb salvage option that is inexpensive and independent of external resources and is a viable option for musculoskeletal tumor management in developing countries.
Modular endoprostheses are a limb salvage option in these situations.
This study is limited by the small sample size and short followup; however, we conclude that use of autoclaved tumor grafts provides a limb salvage option that is inexpensive and independent of external resources without sacrificing appropriate oncologic principles.
For those with intact limbs, one option remains: exert more force on the ground.
Distal femoral replacement implants should be considered as a limb-salvage option when other surgical options are not feasible.
