What is Limb Salvage?
Limb salvage surgery encompasses all surgeries performed with the aim of removal of bone or soft tissue tumour and reconstruction of the limb with an acceptable oncologic, functional, and cosmetic result.
What are the aims of limb salvage surgery?
The aims of limb salvage surgery are
1) To achieve complete removal of sarcoma from oncological point of view
2) To reconstruct the defect thereby allowing maximum possible function taking into consideration the age, site and socio-economic status of the individual
3) To allow adjuvant therapy to be provided to prevent oncological failure.
Who are candidates for limb salvage?
Expertise of treating surgeon and modern techniques in complex reconstruction has allowed every individual suffering from sarcoma to be considered a candidate for limb salvage surgery. Effective chemotherapy and multi-disciplinary approach has also played its part.
In what stage is limb salvage surgery possible?
Patient’s sarcoma prognosis has some impact on the decision to perform limb salvage. Presently, limb salvage is possible in nearly 95 % of sarcoma conditions. The earlier the stage, the better is the result. Limb salvage can even be performed in stage IV or metastatic situation for palliative means. Rarely, amputation is performed when limb salvage is contraindicated.
Are there conditions when limb salvage cannot be performed?
Limb salvage is absolutely contra-indicated in instances of: 1) Extensive growth or involvement involving the blood vessels and nerves which is irreparable; 2) Improperly performed extensive biopsy techniques performed without the idea of limb salvage and 3) Presence of infection or severely immunocompromised status.
Pathological fractures and vascular involvement which can be repaired can still undergo limb salvage surgery.
What are the tests done before limb salvage surgery?
The step-wise timely, coordinated multi-disciplinary approach to sarcoma which requires limb salvage is as follows:
- Clinical history and physical examination.
- Imaging techniques such as X-ray, MRI, CT Thorax
- Biopsy with or without image guidance performed preferably by the musculoskeletal oncosurgeon who performs limb salvage.
- Staging which involves PET CT (FDG/NaF) or Bone scan with CT scan of chest.
- Personalised approach after multi-disciplinary tumour board discussion
- Patient education and counselling
- Neo-adjuvant chemotherapy
What are the types of limb salvage?
Limb salvage has evolved over last 3 decades. As a result of constant improvement and innovation, various options are currently available as follows:
- Tumour Megaprosthesis/ Endoprosthesis
- Expandible Megaprosthesis/ Endoprosthesis in children (Invasive/ Non-Invasive)
- Massive Bone Allograft (Osteoarticular, Intercalary reconstruction)
- Autograft (Iliac crest, Vascularized/ Non-Vascularized Fibula)
- Extra-corporeal Radiation & Reimplantation (ECRT- Tumor Autograft)
- Arthrodesis with Massive Bone Allograft/Autograft
- Allograft Prosthesis Composite (APC)
- Intercalary segmental prosthesis
- Limb reconstruction with Ilizarov, LRS
- Van ness Rotationplasty
What is Tumour Endoprosthetic/ Megaprosthetic reconstruction?
A tumour megaprosthesis or endoprosthesis is a large metallic device designed to replace the excised length of bone and the adjacent joint. Currently, modular designs allow excellent reconstruction options specific to patient demands. The prosthesis is fixed to the host bones with or without bone cement. Additional soft tissue reconstructive procedure is carried out to enable greater stability and rapid mobilization of the patient following surgery. In children, expandable tumour prosthesis are implanted, which can be lengthened to match the natural growth.
What is Biological reconstruction?
Biological reconstruction involves reconstructing the bone defect with either host bone ( Autograft/Vascularised fibula/Tumor Autograft) or (Allograft), thereby leading to a biological healing response. These grafts can be utilized in procedures such as Intercalary reconstruction (which saves the adjacent joints), arthrodesis or in joint reconstructions (Osteo-articular). This type of limb salvage is preferred in children and adolescents due to the long term reliability issues with tumour endoprosthesis.
What is the function accepted after limb salvage surgery?
Limb salvage surgery is recommended over amputation in majority of bone sarcoma situations due to the inherent advantage of a preserved, functional limb. The resultant functional outcome of the limb salvage is often related to the extent of the removal of sarcoma, as well as the technique employed in reconstruction. Endoprosthetic/Megaprosthetic reconstructions allow functional joint movement, suitable for routine daily activities. Such individuals can walk with full weight on the operated limb within few days from surgery. Biological reconstructions involving lower limb and pelvis require a long period of non-weight bearing or limited weight-bearing mobilization to allow bony union and graft incorporation.
What are the complications associated with Limb Salvage surgery?
Complications associated with Limb salvage surgery are as follows in decreasing order:
- Deep periprosthetic infection
- Failure of muscle and soft tissue cover
- Aseptic loosening, fracture of components, wear & tear of bushing components
- Delayed union, Nonunion or fracture of bone graft, Implant failure
- General complications involved in all major limb and pelvic surgeries such as neurovascular injury, deep vein thrombosis, pulmonary embolism, tourniquet related complications and intra or postoperative blood loss.
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