May 30, 2024

Limb Salvage Surgery is a set of surgical procedures designed to remove malignant tumors and reconstruct the limb with acceptable oncological, functional, and cosmetic results.

Indications

Every patient with a tumor of the extremity should be considered for limb salvage if the tumor can be removed with an adequate margin and the resulting limb is worth saving

No justification for limiting the limb salvage process based on the prognosis.

Barriers to Limb Salvage

  • Poorly placed biopsy incision
  • Major neurovascular involvement
  • Displaced pathological fracture
  • Fungating and infected tumors
  • Recurrence of malignant tumor
  • Inability to afford chemotherapy

Vascular involvement is not an absolute contraindication for limb salvage surgery as vascular homograft can be used for reconstruction (Bypass surgery)

Three Strike Rule

  1. Bone
  2. Nerve
  3. Vessels
  4. Soft tissue envelop

Any 3 of the above 4 if affected, LSS is not possible

Goals of limb salvage surgery

  1. Painless limb
  2. Functional, tumor-free limb
  3. Good psychological outcome

Staging

An important step in formulating a treatment plan

The histological type of tumor, Local extent, the possibility of metastasis

  • Radiological staging
  • Surgical staging

Principles

  1. Resection of tumor
  2. Skeletal Reconstruction
  3. Soft tissue and muscle transfer

Resection of tumor

  • Intralesional
  • Marginal
  • Wide resection
  • Radical resection

Adequate margin is always controversial

  • 3 cm for bone
  • 1-2 cm for soft tissue
  • Confirm with the frozen section

Surgical Adjuvants

Local physical and chemical agents

  • Cryosurgery
  • Methyacrylate augmentation
  • Nitrogen mustard, Merthiolate, Hypertonic saline
  • Carbolic acid
  • High concentration ethanol
  • Bisphosphonates in GCT of bone

Chemotherapy: Neoadjuvant or adjuvant

Radiotherapy:

Immunotherapy:

  • Specific: Active and passive
  • Nonspecific: IFN and CSFs

Reconstructions

  • Arthrodesis
  • Osteoarticular allograft
  • Endoprosthesis replacement
  • Allograft prosthetic composite (APC)
  • Rotationplasty
  • Autoclaved tumor bone

Resection Arthrodesis

  • With acute docking and shortening
  • With bone grafting
    • Allograft
    • Autograft
    • Autoclaved bone tumor graft

Fixation

  • Internal: Long ILNs, Plating
  • External: Ilizarov, External fixators, Charnleys clamp

Allograft:

AdvantagesDisadvantages
Length can be adjustedLong healing time
Biological soft tissue healingPotential for transfer of disease and infection
Avoids the risks and complications of intramedullary fixation of the endoprosthesisImmune rejection
Direct attachment of remaining musculatureThe necessity of articular surface size matching
Fracture, Infection, Nonunion

Example: Vascularized fibula graft

Endoprosthesis:

The large metallic device is designed to replace the excised length of the bone and the adjacent joint

Modified hinge design

Allograft Prosthetic Composite (APC)

Allograft: provides a source of bone stock and site for tendon insertion

Prosthesis: Provides reliable and stable articulation and some support to allograft

Rotationplasty

Amputation of the leg above the knee, lower leg, and foot are rotated 180°, the tibia is then fused to the proximal femur

Ankle now functions in place of knee joint

Limb salvage surgery in :

UpperExtremityLowerExtremity
HandArthrodesis/ reconstructionAnkleArthrodesis/reconstruction
WristArthrodesis/ reconstructionKneeArthrodesis/ reconstruction
Elbow ReconstructionFemurArthrodesis / reconstruction
HumerusArthrodesis/reconstructionPelvisArthrodesis/ reconstruction/reconstruction
ScapulaeScapulectomy/ reconstructionHipArthrodesis/ reconstruction

In Children

  • Treatment similar to adults using a smaller version of the modular prosthesis
  • For children younger than 5 years:- Primary amputation remains the preferred solution
  • So, from 5-to 12 years is a challenging area
    • Expandable prosthesis
    • Distraction orthogenesis
    • Rotationoplasty

Skin Closure

  • Extraskin along the incision area should be resected to avoid (d/t large tumor) marginal necrosis due to regional devascularization
  • Sometimes the skin is lesser: Go for SSG
  • Limb elevation in post operative period: to reduce swelling
  • Large bone suction drains are always placed
  • If hematoma or wound breakdown:- Immediate exploration to avoid infection of the endoprosthesis

See also: Radiograph of Bone Tumor