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
- Bone
- Nerve
- Vessels
- Soft tissue envelop
Any 3 of the above 4 if affected, LSS is not possible
Goals of limb salvage surgery
- Painless limb
- Functional, tumor-free limb
- 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
- Resection of tumor
- Skeletal Reconstruction
- 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:
| Advantages | Disadvantages |
|---|---|
| Length can be adjusted | Long healing time |
| Biological soft tissue healing | Potential for transfer of disease and infection |
| Avoids the risks and complications of intramedullary fixation of the endoprosthesis | Immune rejection |
| Direct attachment of remaining musculature | The 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 :
| Upper | Extremity | Lower | Extremity |
|---|---|---|---|
| Hand | Arthrodesis/ reconstruction | Ankle | Arthrodesis/reconstruction |
| Wrist | Arthrodesis/ reconstruction | Knee | Arthrodesis/ reconstruction |
| Elbow | Reconstruction | Femur | Arthrodesis / reconstruction |
| Humerus | Arthrodesis/reconstruction | Pelvis | Arthrodesis/ reconstruction/reconstruction |
| Scapulae | Scapulectomy/ reconstruction | Hip | Arthrodesis/ 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
