Limb Salvage Fundamentals
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.
What are my treatment options?
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.
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.
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.
- Allograft bone replacement: Allograft bone replacement involves using bones that have been preserved from persons who have died and, as an altruistic gift, have donated organs and tissues. These donors have been carefully screened for diseases, including HIV and hepatitis infection. The bones of the person receiving the allograft will heal to the allograft and grow into it, partly replacing the allograft with the person's own bone. Rejection of the bone is rare, since there are few fragments of the donor's cells in the allograft to induce a reaction. The bone itself is relatively inert. The greatest problems with allograft reconstruction are the chance of infection, graft fracture, or failure of healing between the graft and the adjacent patient bone. Each of these complications occurs about 10% of the time. Fracture and non-union can usually be treated successfully. Treatment of an infected graft usually requires removal of the allograft.
- Endoprosthesis: Metal endoprosthesis (an implantable metal replacement) have revolutionized the field of limb salvage. Prostheses used for reconstruction of tumors must replace both the joint surface and a large segment of bone adjacent to the joint. Ten years ago, most of these endoprosthesis were custom-made and required four to six weeks’ preparation, precluding their use in urgent situations. Today, we have almost immediate access to these prostheses. Prostheses can be implanted with or without bone cement.
- Tissue regeneration: Tissue regeneration is a rapidly evolving field. New concepts of tissue engineering are beginning to be applied to reconstructive procedures to improve the results of limb salvage. Tissue engineering uses combinations of a patient’s own cells, synthetic matrix materials and purified protein growth factors to induce the regeneration of the patient’s own tissue. The Cleveland Clinic is a leader in this exciting field. Additionally, bone can be transported and made to grow a millimeter per day (one inch per month) using the Ilizarov or spatial frame technique.
- Fusion of a joint: Occasionally, when there is not enough muscle around a joint to provide mobility, the surgeon may recommend making the joint rigid by having the ends of the joint heal together.
What are the risks of surgery?
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.
How do I prepare for surgery?
- Complete any pre-operative tests or lab work prescribed by your doctor.
- Arrange to have someone drive you home from the hospital.
- Refrain from taking aspirin and non-steroidal anti-inflammatory medications (NSAIDs) one week prior to surgery.
- Call the appropriate surgery center to verify your appointment time. If your surgery is being done at Cleveland Clinic, call 216.444.0281.
- Refrain from eating or drinking anything after midnight the night before surgery.
Are there exercises I can start now prior to surgery?
Patients with lower extremity procedures most likely will require crutches. Physical therapy, including crutch instruction, is easier to accomplish before the surgery.
What do I need to do the day of surgery?
- If you currently take any medications, take them the day of your surgery with just a sip of water.
- Do not wear any jewelry, body piercing, makeup, nail polish, hairpins or contacts.
- Leave valuables and money at home.
- Wear loose-fitting, comfortable clothing.
What happens after surgery?
A post-operative instruction sheet will be provided.
How long is the recovery period after surgery?
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.
What is the rehab after surgery?
Depending on the procedure, physical therapy for crutch use, range-of-motion and strengthening may be required.
How can I manage at home during recovery from the procedure?
Instructions from the physician will be provided. These will vary according to the procedure.