Limb Salvage
Limb salvage has greatly helped individuals who are affected by malignant tumors from the neck to the hand and from the pelvis to the foot. Twenty years ago, for all but a few patients, a malignant tumor meant an amputation. Either the risk of leaving the tumor behind was too great, or there was no viable means of reconstructing the limb to provide acceptable function after the tumor was removed.
Thankfully, dramatic advances in technology have made it possible to safely treat malignant tumors without resorting to limb removal. Sometimes, though not always, this can be done with little or no long-term problems with the overall daily function of the limb.
Cleveland Clinic orthopaedic surgeons were among the first in the country to adopt limb salvage as an alternative to amputation in children and adults with malignant tumors; to resect complex tumors; and to undertake reconstruction using allograft bone and endoprosthesis.
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Because many tumors will respond dramatically to chemotherapy and/or radiation therapy, these methods are often begun before any surgery is done to surgically remove the tumor. This strategy, called “neo-adjuvant therapy” or pre-operative treatment has two important benefits.
One, if the tumor does respond dramatically, it may shrink. Smaller tumors are often easier to remove, and may allow the surgeon to save some tissues and key structures such as nerves and vessels.
Second, the response of the tumor to chemotherapy determines whether the chemotherapy is working. If the tumor responds dramatically, the therapy is continued. If there is little or no response, the therapy should be stopped or changed. This strategy has had a dramatic effect on our ability to cure individuals with many malignant tumors. This is particularly true for osteosarcoma. Before chemotherapy was used, only one in 20 patients with osteosarcoma was cured, despite aggressive use of amputations. Our experience at The Cleveland Clinic, and reports from other major centers, has shown that 60% to 65% of patients with osteosarcoma can be cured without amputation. If the patient responds well to chemotherapy for osteosarcoma, he or she has an 85% to 90% long-term survival rate.
Pre-op
Saving a limb requires two things. First, the physician must be confident that he or she can remove the tumor safely without contamination of the resection field (spilling of tumor) – tumor recurrence will lead to a significant increase in the risk of dying from a tumor. Second, the physician must have a plan for reconstruction of the limb. MRI and CT imaging enable a surgeon to make a detailed surgical plan and has eliminated much of the uncertainty about the location and extent of a tumor.
Post-op
Once the tumor has been removed, reconstruction begins. Reconstruction can include reconnecting or replacing major blood vessels. In some cases, methods are available for the transfer of muscles to replace removed muscles. In other situations, advanced plastic surgery procedures can be used to borrow tissues from other sites and move them where they are needed. In some cases, nerve grafts or nerve repairs may be performed.
One of the biggest challenges faced by surgeons has been the reconstruction or replacement of large segments of missing bone. Many options are available. These options can be generally grouped into three categories: reconstruction with allograft bone, reconstruction with metal parts (endoprosthesis), and reconstruction using tissue regeneration.
The function of a limb reconstructed with either an allograft or endoprosthesis is primarily dependent on the strength of muscles around the adjacent joint, and can rival the function of a normal limb or a conventional hip or knee replacement. Each technique has advantages and disadvantages. Allografts have the disadvantage of a higher rate of early complications (infection, fracture, non-union). However, the advantage of allografts is that they become stronger and are less likely to require additional surgery over time.
In contrast, an endoprosthesis has a lower risk of early complications, but the likelihood of needing additional surgery is higher. The life span of these prostheses is limited to an average of 15 years, sometimes less. This means that a young person having a reconstruction of this type is almost certain to need a revision in the future. Revisions can usually be done without compromising the functional result, but are costly and preferably avoided.
Patients with lower extremity procedures most likely will require crutches. Physical therapy, including crutch instruction, is easier to accomplish before the surgery.
A post-operative instruction sheet will be provided.
The recovery period depends upon the bone lesion and location. Wound healing takes about two weeks. If bone healing is necessary, the physician may require patients to protect the extremity for six weeks from major forces such as full weight-bearing.
Depending on the procedure, physical therapy for crutch use, range-of-motion and strengthening may be required.
Instructions from the physician will be provided. These will vary according to the procedure.
Reviewed by a Cleveland Clinic medical professional.
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