Limb salvage

ALSO KNOWN AS: Limb sparing

DEFINITION: Limb salvage surgery includes all surgical procedures designed to remove a malignant tumor and resection the limb with an acceptable oncologic, functional, and cosmetic result.

Cancers treated: Soft-tissue neoplasias (malignant fibrous histiocytoma, fibrosarcoma, liposarcoma, rhabdomyosarcoma, synovial sarcoma); bone malignancies (osteosarcoma, chondrosarcoma, adamantinoma, Ewing sarcoma)

Why performed: In the past, most sarcomas were treated by amputation. Tumor recurrence, metastasis, and a generally dismal prognosis had been powerful deterrents to any progress in the surgical treatment of such tumors. Since the late 1980s, however, limb salvage has all but replaced amputation as the treatment of choice for sarcomas of the extremities. This dramatic change resulted from two important developments: effective chemotherapy and precision imaging technology. In the twenty-first century, up to 95 percent of extremity sarcomas are treated with limb salvage surgery.

Limb salvage surgery (LSS) can result in survival rates and disease-free intervals that equal those previously achieved with amputation. The presumed functional and psychological advantages of LSS over amputation are in the process of being established. LSS appears to allow better psychological functioning with a more intact body image, but it is more complex and demanding than amputation and is associated with increased morbidity. The duration of surgery is longer. Infection, pain, and other complications are more common with LSS. Barriers to limb salvage include major vascular involvement, encasement of a major motor nerve, and a of the involved bone.

Patient preparation: Both imaging studies and biopsy results are used to stage bone and soft-tissue sarcomas. Staging of the tumor influences preoperative chemotherapy or radiation treatments and allows the surgeon to begin planning the limb salvage procedure. The preoperative treatment period allows the surgeon to meet with the patient and family to discuss the choice of the surgical treatment. Treatment by amputation remains a viable and sometimes preferable option, and it should be openly discussed with the patient in an unbiased manner. Every patient with a malignant tumor of the extremity should be considered for LSS if the tumor can be excised with an adequate tissue margin, resulting in a limb worth saving. A limb worth saving needs an acceptable degree of function and cosmetic appearance with a minimal amount of pain, and it needs to be durable enough to withstand the demands of normal daily activities.

Steps of the procedure: Surgical treatment of musculoskeletal neoplasms of the extremities is complex and varied. Tumors occur in all anatomic locations of the extremity, and surgical procedures must be tailored to each location. Three principles are involved in any operation for extremity sarcomas: excision of the tumor, skeletal reconstruction, and soft-tissue reconstruction. Obtaining an adequate surgical margin takes precedence over all other considerations. If an adequate surgical margin can be achieved only with an amputation, then the patient must be so informed and must understand that doing less will compromise the chances for long-term survival.

Advances in medicine and technology have made LSS an even more viable option as the twenty-first century progressed. Improved surgical techniques have increased the positive outcomes and allowed patients to have increased functionality. Imaging techniques have improved, and new chemotherapy medications have been introduced. Non-invasive implants with magnetic coils have been developed. High-Intensity Focused Ultrasound has also allowed for non-invasive LSS treatments. 

After the procedure: The rehabilitation process is performed by a team. Steps in the process include a preoperative physical examination of limb function and disability. Pretraining of the patient is necessary to reduce the rehabilitation time and to lessen the emotional stress following surgery.

Age, surgical site, use of allograft bone, the implementation of soft-tissue flap coverage, residual function of associated joints, the possibility of joint reconstruction, use of appropriate orthoses and splints, and palliative care will influence, modify, and direct physical and occupational therapies.

Risks: LSS is an extensive series of procedures involving masses of soft tissues, bones, and joints. In contrast to ordinary orthopedic procedures, in which the goal is to solve a local problem with minimal exposure and damage, limb salvage deliberately damages many anatomic areas and may cause the following problems:

• bone and joint damage
• muscle damage
• skin damage
• nerve damage (due to mobilization of major nerves and direct damage resulting from radiotherapy and agents)
• vascular damage (vessel damage and spasm during surgical exploration and excision of major vessels as a result of tumor involvement)
• damage to the lymphatic system (resulting in chronic swelling and limb edema)
• scars (pain, dysesthesias, restricted range of movement)
• short and long-term risk of infections (in 10 percent of cases)
• effects of cancer treatments (radiotherapy, chemotherapy)

Radiotherapy damages the skin, subcutaneous tissues, and muscles, causing fibrosis, decreased tissue elasticity, and contractures. Radiation can result in increased bone fragility and the additional risk of fractures. Chemotherapy may cause chronic weakness and fatigue. It requires repeated hospitalizations, which makes it difficult to maintain the intensity and continuity of a rehabilitation program.

Results: Limb-sparing surgery is now widely accepted as a treatment option for extremity sarcomas. Numerous reports confirm low recurrence rates after tumor resection with adequately wide margins. Studies about functional loss following such procedures are limited; however, returning functionality depends on a patient's commitment to post-procedure rehabilitation. For many patients, normal function can return within a year.

Bibliography

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