Limb Salvage in Orthopedic Oncology: Aim, Types, and Advantages

What Is Limb Salvage?

Limb salvage is the surgical procedure involving removing the bone tumor without removing the tendons, nerves, and blood vessels adjacent to it (which means no amputation). This procedure is done by removing the tumor and 1 inch of the healthy tissues. The removed part may be replaced with metal rods, bone grafts, and prostheses. This limb salvage procedure is often done along with chemotherapy or radiotherapy. Researchers have shown that limb salvage possesses better psychological and functional outcomes. It is also studied that the recurrence rate and spread of the tumor have decreased while performing limb salvage procedures when compared to amputation procedures. Limb salvage surgery is also called limb-sparing surgery.

What Is Orthopedic Oncology?

Orthopedic oncology refers to the study, diagnosis, and treatment of malignant conditions of the musculoskeletal system. Orthopedic oncologists often treat musculoskeletal disorders like primary bone cancers, soft tissue sarcomas, breast cancer, prostate cancer, and colon cancer that involve bones. Usually, sarcomas and bone cancers require a combination of surgeries and therapies to restore the mobility of limbs and promote their functions, appearance of the limb, and durability.

What Is the Aim of Limb Salvage in Orthopedic Oncology?

The main aims of limb salvage procedure in musculoskeletal tumors include:

• To perform a complete removal of primary bone tumors and soft tissue sarcoma from an oncological view.

• To involve reconstructing the defect and maximizing the limb's function by considering the patient's age, socioeconomic status, and size.

• To allow additional therapies to be performed to prevent failure caused by recurrence and spread of the infection.

Who Can Undergo Limb Salvage Procedures?

Even though the limb salvage procedure has several advantages over the amputation procedure, it can not be performed in all sarcoma cases. There are certain limitations and conditions that a person needs to undergo a limb salvage procedure. It can be performed only when a person meets the following criteria, which include:

• Limb salvage can not be performed if there is a large growth that involves nerves and blood vessels which can not be repaired.

• It is also limited in patients with improperly performed biopsy procedures that are done without the idea of requiring a limb salvage procedure.

• It is contraindicated for severely immunocompromised patients and in severe infection cases.

What Are the Types of Limb Salvages Used in Orthopedic Oncology?

There are several types of limb salvage procedures used for various types of malignant tumors of the bone. Some of the types that are used to treat bone sarcomas include:

• Tumor mega prosthesis reconstruction.

• Growing tumor prosthesis or expandable prosthesis for children.

• Rotationplasty.

• Biological reconstruction.

• Tumor excision and flap reconstruction.

• Bone autograft.

• Scapulectomy and reconstruction.

• Bone allograft.

• Ulna translocations and wrist arthrodesis.

• ECRT (extracorporeal radiation and reimplantation).

• Nail or plate cement spacer reconstruction.

• Vascularized fibula.

• 3D printed model and implant surgery.

• Cryotherapy.

• Internal hemipelvectomy and reconstruction.

• Graft prosthetic composite reconstruction.

• Intercalary segmental prosthesis.

What Are the Diagnostic and Treatment Criteria Done Before Limb Salvage Surgeries?

The diagnostic and treatment approach of bone sarcoma include

• Medical history and physical examination.

• Imaging tests include X- rays, MRI (magnetic resonance Imaging), and CT (computed tomography) thorax.

• Biopsy using imaging guidance or without imaging guidance is preferably performed by the surgeon who will perform limb salvage surgery.

• Tests to stage the tumor include a chest CT or PET(Positron Emission Tomography) CT (FDG/NaF) bone scan.

• Patient education and counseling.

• Neoadjuvant chemotherapy.

What Are the Advantages of Limb Salvage Surgery in Orthopedic Oncology?

There are several advantages of limb salvage procedure compared to amputation and other treatment modalities for sarcomas. The availability of navigation assistance, customized prosthesis designs, and 3D-printed implant surgeries have improved the functional outcomes of limb salvage procedures. Some of the major advantages of limb salvage in orthopedic oncology include:

• Limb preservation by limb salvage surgery has overcome a major disadvantage of amputation. It majorly helps in preserving the limbs and maintaining some of their functions instead of entirely removing the part and impacting the quality of life of a person.

• Studies have shown that limb salvage surgery in bone tumors has provided better gait efficiency and made people return to their normal life compared to amputation.

• Considering all the advantages of limb salvage surgery, doctors recommend that over 95 percent of bone sarcoma patients be treated with limb salvage surgeries.

What Are the Risk Factors Associated With Limb Salvage Surgery in Orthopedic Oncology?

Like all major surgical procedures, limb salvage surgery is also a major procedure with all common side effects and complications. Some of the complications of limb salvage are:

• Deep periprosthetic infection.

• Peri prosthetic fracture.

• Risk of infections of surrounding soft tissues.

• Prosthetic loosening.

• Prosthetic dislocation.

• Allograft fracture.

• Nonunion of host graft junction.

• Leg length discrepancy.

• Implant failure.

• Delayed union of graft host junction.

• Deep vein thrombosis.

• Pulmonary embolism.

• Neurovascular injury.

• Preoperative blood loss.

• Need for additional surgery as the lifespan of prostheses is only 15 years or even less than that.

How Can a Person Promote Their Health After a Limb Salvage Surgery?

• Physical therapy and occupational therapy may play a vital role in the rehabilitation after limb salvage. In addition to this, limb function can be maintained by performing a range of motion exercises.

• Taking proper antibiotics while doing certain medical and dental procedures may be beneficial as it has a long-term risk for infections.

Conclusion

Limb salvage procedures in orthopedic oncology are vital in treating bone sarcomas and soft tissue sarcomas. Its main function is to preserve the limb as much as possible when compared to amputation, which requires the removal of the entire limb. Limb salvage surgery preserves the affected part's nerves, tendons, and blood vessels. As it is a difficult surgical procedure, it should be performed by specialized oncology surgeons. Reaching out to healthcare professionals may be beneficial.