Limb Salvage Surgery

 

LIMB SALVAGE SURGERY: Preserving Function and Life

 

Introduction:

• Limb salvage surgery is a groundbreaking approach to treating limb sarcomas that involves removing malignant tumors while preserving the affected limb and improving the quality of life. This procedure offers significant benefits, including functional and aesthetic restoration.
• In this article, we will explore the advantages, candidate selection, various surgical techniques, outcomes, and rehabilitation associated with limb salvage surgery.

Benefits of Limb Salvage Surgery:

• Limb salvage surgery provides numerous advantages compared to traditional amputation.
• By preserving the limb, individuals can maintain their mobility, independence, and overall quality of life.
• Moreover, it contributes positively to their self-image and psychological well-being, reducing the emotional impact often associated with limb loss.

Candidate Selection:

• Limb salvage surgery is the primary treatment approach for most individuals with limb sarcomas.
• Factors considered when determining candidacy include tumor type, location, stage, response to neoadjuvant therapies, and the patient’s overall health.
• With advancements in surgical expertise, reconstruction techniques, and supportive therapies, an increasing number of patients now qualify for limb salvage procedures.

Types of Limb Salvage Procedures:

Limb salvage surgery encompasses various techniques tailored to individual needs. These include tumor resection, reconstruction using prosthetic implants, biological reconstruction with grafts, and specialized techniques like rotationplasty. Soft tissue reconstruction methods are also employed to address defects and restore limb aesthetics.

• Tumour Megaprosthesis/ Endoprosthesis
  • Adult
  • Expandable Megaprosthesis/ Endoprosthesis in children (Invasive/ Non-Invasive)
  • Intercalary segmental prosthesis

• Biological Reconstruction
  • Massive Bone Allograft (Osteoarticular, Intercalary reconstruction)
  • Autograft (Iliac crest, Vascularized/ Non-Vascularized Fibula)
  • Extra-corporeal Radiation & Reimplantation (ECRT- Tumor Autograft)
  • Cryotherapy and reimplantation
  • Limb reconstruction with Ilizarov, LRS
  • Arthrodesis with Massive Bone Allograft/Autograft

• Allograft Prosthesis Composite (APC)
• Van ness Rotationplasty

What are the deciding factors ?

• Patient and disease factors such as
  • Age
  • Site
  • Diagnosis
  • Stage of sarcoma
  • Response to neoadjuvant chemotherapy
  • Socio-economic factors

When is limb salvage not be performed?

Limb salvage is absolutely contra-indicated in instances of

• Extensive skin and muscle involvement precluding adequate coverage and function
• Improperly performed extensive biopsy techniques performed without the idea of limb salvage
• Major Neurovascular involvement
• Presence of infection or severely immunocompromised status.

Limb salvage is challenging but can still be performed in certain conditions

• Vascular involvement which can be reconstructed
• Pathological fractures which may need extensive surgery.
• Soft tissue defect which can be reconstructed by Major flap surgeries

What are the crucial steps ?

The stepwise timely, coordinated multidisciplinary approach to sarcoma which requires limb salvage is as follows:

• Thorough history and general physical examination.
• Imaging techniques such as X-ray, MRI, CT Thorax
• Biopsy (minimally invasive) with or without image guidance performed preferably by the surgeon who performs limb salvage.
• Staging of sarcoma which involves PET CT (FDG/NaF) or Bone scan.
• Individualized approach after discussion in a multi-disciplinary sarcoma meeting.
• Patient education and counselling
• Neoadjuvant chemotherapy or rarely neoadjuvant

Oncological Considerations:

• Limb salvage surgery prioritizes both oncological clearance and functional outcomes.
• Surgeons strive to achieve complete tumor removal with clear margins, reducing the risk of local recurrence.
• Adjuvant therapies such as chemotherapy or radiation may be recommended to target any remaining cancer cells.
• Regular follow-up and surveillance are crucial for long-term monitoring of the individual’s oncological status and overall well-being.

Outcomes and Rehabilitation:

• Successful limb salvage surgery involves a comprehensive rehabilitation program to optimize functional outcomes and aid in the individual’s return to daily activities.
• Physical therapy, occupational therapy, and psychological support form integral parts of the rehabilitation process.
• This holistic approach helps patients regain strength, mobility, and adaptability, facilitating their transition to an active and fulfilling life.

Conclusion:

• Limb salvage surgery has revolutionized the treatment of limb sarcomas, offering a comprehensive approach that preserves limb functionality and aesthetics while ensuring oncological clearance.
• With advancements in surgical techniques, reconstruction options, and supportive therapies, more individuals can benefit from this limb-preserving approach.
• By combining surgical expertise, multidisciplinary collaboration, and personalized rehabilitation, limb salvage surgery continues to improve the lives of sarcoma patients, empowering them to lead fulfilling and productive lives.