LIMB SALVAGE SURGERY
Sarcoma involving the limbs have been conventionally been treated surgically by amputations.
Even now, most patients undergo limb amputation in several countries.
With recent advances in surgical skills, availability of reconstruction options and various implants, limb salvage surgery is now possible in most cases.
Chemotherapy and radiotherapy given before surgery has also helped in reducing the size of the tumor locally so that the surgical removal becomes easy and safe.
Various options have evolved which can be chosen based on the type, site, grade and extent of cancer.
Also patient age, social and occupational requirements are also kept in mind while choosing the type of reconstruction method.
What is Limb Salvage Surgery?
Limb salvage surgery includes all of the surgical procedures designed to accomplish removal of a malignant tumor
Followed by reconstruction of the limb with an acceptable oncologic, functional, and cosmetic result.
What are the goals of limb salvage?
- To achieve complete removal of sarcoma from oncological point of view
- To reconstruct the defect thereby allowing maximum possible function taking into consideration the age, site and socio-economic status of the individual
- To allow adjuvant therapy to be provided to obtain better oncological response.
Who are candidates for limb salvage surgery?
- With the increasing expertise of treating surgeons and availability of modern techniques of reconstruction, limb salvage is provided as the first solution to all or nearly 95 % of individuals suffering from sarcoma.
- This advancement is in part also attributed to development of effective chemotherapy and precise imaging techniques allowing the surgeon to improve results.
Is limb salvage possible in all stages of sarcoma?
- Patient’s sarcoma prognosis has little impact on the decision to perform limb salvage.
- Presently, limb salvage is possible in nearly 95 % of sarcoma conditions.
- The possibility and final result is better when the individual is identified in the early stages.
- Nevertheless, even in stages of extensive local disease or systemic spread to lungs for example it is possible to achieve limb salvage and treat metastases leading to an acceptable final result.
- In certain situations such as extensive local and systemic disease, limb salvage can be performed for palliative purposes to improve the quality of life.
What are the deciding factors to provide limb salvage?
Patient and disease factors such as
- stage of sarcoma
- response to neoadjuvant chemotherapy
- socio-economic factors
What are the instances where limb salvage cannot 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 before performing limb salvage?
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
What is oncological clearance in limb salvage?
- Sarcomas have a tendency to spread systemically (metastasis) or locally recur either with or without limb salvage.
- The purpose of limb salvage is to completely remove tumors with safe normal healthy tissue margins all around sarcoma, thereby reducing the risk of local recurrences even up to 2-3 %.
- The removal of sarcoma also helps in reducing the disease load in the body allowing adjuvant chemotherapy or radiotherapy to target the microscopic disease and reduce the chance of metastases.
- Technically, all sarcoma cases are dealt with the intention of complete removal with wide healthy tissue margins.
Due to circumstances related to anatomical and pathology of disease it is sometimes difficult to abide strictly by wide healthy margins thereby resulting in compromised or contaminated margins which may involve some contamination during removal of sarcoma.
These instances may have higher risk of local recurrence of sarcoma and may necessitate adjuvant therapy like radiation to the affected part.
- Currently, the incidence of compromised margins during sarcoma removal is further reduced due to availability of precise imaging techniques which allow the surgeon to plan and execute the surgery better.
What are the types of limb salvage?
Limb salvage has evolved tremendously since the 1980’s in the world.
Result of this constant improvement and innovation has led to options such as Arthroplasty, Arthrodesis, and Rotationplasty utilizing bone grafts, metal & polymer components.
- Tumour Megaprosthesis/ Endoprosthesis
- 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
Amputation does not amount to limb salvage.
What are the functional and psychological outcomes of limb salvage surgery?
- Every individual with sarcoma of limb or axial skeleton is provided multi-disciplinary customized treatment.
- The resultant functional outcome of the limb salvage is related to the extent of the removal of sarcoma, as well as the technique employed in reconstruction.
- It is difficult to compare the limb salvage modalities since the indications may also differ.
To emphasize, the aims of limb salvage surgery involves complete removal of sarcoma foremost followed by the most acceptable and suitable reconstruction based on the needs and socio-economic status of the patient.
- Endoprosthetic/Megaprosthetic reconstructions allow joint movement in the range of 0-120 degrees for the knee and varying degrees of other joints in the functional range.
They are made to walk with full weight on the operated limb within a few days from surgery.
These individuals are not advised to continue squatting, sitting cross legged or indulge in heavy demand for physical labor but can involve in light or non-contact sports.
- 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.
Patients with arthrodesis of the knee perform the most demanding physical and recreational activities, but have difficulty sitting.
- Patients with Rotationplasty are more active and are the least worried about limb injury.
- Amputation results in impaired ambulation even with external prosthesis. There are reports of difficulty in personal relationships or social activities in patients with Rotationplasty or amputation due top cosmetic reasons.