Overview
Limb salvage surgery is usually performed to remove malignant bone tumours.
Otherwise referred to as limb-sparing surgery, it involves removing cancer and at least an inch of the surrounding tissues. Unlike the amputation of the entire limb for malignant bone tumours, the surgery gives patients a chance to keep the limb in which a tumour is located.
Surgery Procedure
Some of the main goals of limb salvage surgery are the following:
- Prevent amputation
- Preserve degree of function in the affected limb
- Remove the cancer
- Preserve the patient’s appearance
Limb salvage surgery has three stages:
- Cancer removal (and at least a margin of healthy tissue)
- Bone graft or prosthesis implant (when needed)
- Closing the wound (this is done by transferring soft tissue or muscle from another part of the body)
Surgery Considerations
Years ago, amputation of the affected extremity was the standard route of treatment for patients with cancer in the limbs. Fortunately, is it no longer the only option available. With significant changes in chemotherapy, imaging methods, and surgical techniques, amputation can now be avoided.
Today, limb salvage surgery has also become an option for individuals who have bone diseases and other chronic degenerative joint conditions like acute limb wounds and rheumatoid arthritis. It has also become an alternative for those who are candidates of diabetic limb amputation.
Prior to deciding if limb salvage is appropriate, doctors take the following key factors into consideration:
- The type of cancer
- The general health of the patient
- Size of the tumour
- Progression of the condition
- Location of the tumour
- Age of the patient
If limb salvage is appropriate, the doctor will inform the patient about the likely outcome, how the procedure would be carried out, and possible additional surgery (even amputation) if the implant fails. The surgery involves removing the tumour along with some of the healthy tissues that surround it. This is because even if only a small number of cancer cells are left behind, they might multiply and develop into a new tumour. Either an artificial limb (synthetic prosthesis) or a bone graft may be used to replace the parts removed.
Surgical Techniques
Soft Tissue Sarcomas – Limb-sparing surgery is the treatment option used in at least 80 per cent of soft tissue sarcomas that affect the extremities. The procedure involves removing the tumour, lymph nodes, as well as the tissues affected by cancer.
Bone Tumors – Surgeons treat low-grade tumours by removing malignant lesions and a cuff of normal tissues. For high-grade tumours, muscles, bones and tissue affected by the tumour are also removed.
Chemotherapy and/or radiation may be required before or after the operation. In some cases, radiation may also be administered during the surgery. A special applicator is placed against the surface where the tumour has been removed and tubes with radioactive pellets are inserted in the tumour site. The tubes will not be removed until several days after.
In cases of soft tissue sarcoma that has spread to the patient’s lung, the surgeon’s likely treatment approach will involve removing the tumour, administering chemotherapy or radiation treatments, and surgically removing the lung tumour.
Aftercare
Patients usually remain in the hospital for about 5-10 days after the surgery. Nurses will be monitoring the blood flow in the extremity affected as well as sensation. They also watch out for possible signs of complications like pulmonary embolism, deep-vein thrombosis, and pneumonia.
Broad-spectrum antibiotics will most likely be prescribed at least for the first 48 hours after the surgery. Medication (prophylactic anticoagulants) will also be given and anti-embolism stockings might be required to prevent blood clots. A drainage tube will also be placed in the wound in the first 24–48 hours to prevent blood and fluid from accumulating in the surgical site.
Exercise Intervention
Since limb salvage surgery will entail extensive surgical incisions, patients will need to undergo extensive rehabilitation. The type of reconstruction, as well as the amount of bone removed, will often affect how much and how soon the patient can exercise, although most patients will begin continuous passive motion (CPM), muscle-strengthening, and range of motion (ROM) exercises a day after the surgery. The aforementioned exercises will be carried out for at least 12 months.
Patients who have had upper-limb surgery may use the body’s opposite side when doing shoulder and hand exercises. For those who have had surgery involving the humerus (the bone between the shoulder and elbow), shoulder and elbow exercises should be avoided the first two to eight weeks after the operation.
Rehabilitation
Occupational and physical therapy routines are designed to help patients function independently, move freely, and accept body image changes. In some cases, even patients who look the same after the operation might feel like the surgery has changed their appearance.
Before the patient is sent home, the doctor will decide whether a brace, cane, walker or other devices will be required. Written instructions on how to recognize and prevent infection will also likely be given.
Risks
Some of the major risks associated with limb salvage surgery include breakage, shifting, or loosening of the implants, loss of sensation or blood flow in the limb affected, deep or superficial infection at the surgery site, anemia, and severe blood loss.
Postoperative infection can also be a serious concern. Since radiation and chemotherapy can weaken the immune system, extensive bone damage might take place before the infection is noticed.
Removing the implant or graft, giving intravenous antibiotic therapy, and inserting drains on the site affected are some of the treatment options for postoperative infections. If all else fails, amputation of the affected limb might be required.
Oftentimes, it will take at least a year for patients with upper-extremity limb salvage to master new ways to use the affected hand or arm. Likewise, it will also take almost the same amount of time for those who have had lower-extremity limb salvage to learn to walk again.