Limb Salvage

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Limb salvage surgery is a type of surgery primarily performed to remove bone and soft-tissue cancers occurring in limbs in order to avoid amputation.

Purpose

Limb salvage surgery is performed to remove cancer and avoid amputation, while preserving the patient’s appearance and the greatest possible degree of function in the affected limb. The procedure is most commonly performed for bone tumors and bone sarcomas, but is also performed for soft tissue sarcomas affecting the extremities. This complex alternative to amputation is used to cure cancers that are slow to spread from the limb where they originate to other parts of the body, or that have not yet invaded soft tissue.

Twenty years ago, the standard of care for a patient with a cancer in a limb was to amputate the affected extremity. Limb salvage surgery was an exception to the rule. Today, it is the exception that a patient loses a limb as part of cancer treatment. This is due to improvements in surgical technique, both resection and reconstruction, imaging methods (computed tomography [CT scan] and magnetic resonance imaging [MRI]), and survival rates of patients treated with chemotherapy.

In recent years, limb salvage has been extended more and more to patients severely affected by chronic

KEY TERMS

Resection— Remove of a part of an organ.

Sarcoma— A form of cancer that arises in the supportive tissues such as bone, cartilage, fat, or muscle.

degenerative bone and joint diseases, such as rheumatoid arthritis, those facing diabetic limb amputation, and those with acute and chronic limb wounds.

Demographics

According to the National Cancer Institute, primary bone cancer is rare, with only 2,500 new cases diagnosed each year in the United States. More commonly, bones are the site of tumors that result from the spread of other primary cancers—that is, from cancers that spread other organs, such as the breasts, lungs, and prostate. Bone cancers occur more frequently in children and young adults.

Description

Also called limb-sparing surgery, limb salvage involves removing the cancer and about an inch of healthy tissue surrounding it. In addition, if had been removed, the removed bone is replaced. The replacement can be made with synthetic metal rods or plates (prostheses), pieces of bone (grafts) taken from the patient’s own body (autologous transplant), or pieces of bone removed from a donor body (cadaver) and frozen until needed for transplant (allograft). In time, transplanted bone grows into the patient’s remaining bone. Chemotherapy, radiation, or a combination of both treatments may be used to shrink the tumor before surgery is performed.

Limb salvage is performed in three stages. Surgeons remove the cancer and a margin of healthy tissue, implant a prosthesis or bone graft (when necessary), and close the wound by transferring soft tissue and muscle from other parts of the patient’s body to the surgical site. This treatment cures some cancers as successfully as amputation.

Surgical techniques

BONE TUMORS. Surgeons remove the malignant lesion and a cuff of normal tissue (wide excision) to cure low-grade tumors of bone or its components. To cure high-grade tumors, they also remove muscle, bone, and other tissues affected by the tumor (radical resection).

SOFT TISSUE SARCOMAS. Surgeons use limb-sparing surgery to treat about 80% of soft tissue sarcomas affecting extremities. The surgery removes the tumor, lymph nodes, or tissues to which the cancer has spread, and at least 1 inch (2.5 cm) of healthy tissue on all sides of the tumor.

Radiation and/or chemotherapy may be administered before or after the operation. Radiation may also be administered during the operation by placing a special applicator against the surface from which the tumor has just been removed, and inserting tubes containing radioactive pellets at the site of the tumor. These tubes remain in place during the operation and are removed several days later.

To treat a soft tissue sarcoma that has spread to the patient’s lung, the doctor may remove the original tumor, administer radiation or chemotherapy treatments to shrink the lung tumor, and surgically remove the lung tumor.

Diagnosis/Preparation

Before deciding that limb salvage is appropriate for a particular patient, the treating doctor considers what type of cancer the patient has, the size and location of the tumor, how the illness has progressed, and the patient’s age and general health.

After determining that limb salvage is appropriate for a particular patient, the doctor makes sure that the patient understands what the outcome of surgery is likely to be, that the implant may fail, and that additional surgery—even amputation—may be necessary.

Physical and occupational therapists help prepare the patient for surgery by introducing the muscle-strengthening, ambulation (walking), and range of motion (ROM) exercises the patient will begin performing right after the operation.

Aftercare

During the five to 10 days the patient remains in the hospital following surgery, nurses monitor sensation and blood flow in the affected extremity and watch for signs that the patient may be developing pneumonia, pulmonary embolism, or deep-vein thrombosis.

The doctor prescribes broad-spectrum antibiotics for at least the first 48 hours after the operation and often prescribes medication (prophylactic anticoagulants) and antiembolism stockings to prevent blood clots. A drainage tube placed in the wound for the first 24–48 hours prevents blood (hematoma) and fluid (seroma) from accumulating at the surgical site. As postoperative pain becomes less intense, mild narcotics or anti-inflammatory medications replace the epidural catheter or patient-controlled analgesic pump used to relieve pain immediately after the operation.

Exercise intervention

Limb salvage requires extensive surgical incisions, and patients who have these operations need extensive rehabilitation. The amount of bone removed and the type of reconstruction performed dictate how soon and how much the patient can exercise, but most patients begin muscle-strengthening, continuous passive motion (CPM), and ROM exercises the day after the operation and continue them for the next 12 months.

A patient who has had upper-limb surgery can use the opposite side of the body to perform hand and shoulder exercises. Patients should not do active elbow or shoulder exercises for two to eight weeks after having surgery involving the bone between the shoulder and elbow (humerus). Rehabilitation following lower-extremity limb salvage focuses on strengthening the muscles that straighten the legs (quadriceps), maintaining muscle tone, and gradually increasing weight-bearing so that the patient is able to stand on the affected limb within three months of the operation. A patient who has had lower-extremity surgery may have to learn a new way of walking (gait retraining) or wear a lift in one shoe.

Goals of rehabilitation

Physical and occupational therapy regimens are designed to help the patient move freely, function independently, and accept changes in body image. Even patients who look the same after surgery as they did previously may feel that the operation has altered their appearance.

Before a patient goes home from the hospital or rehabilitation center, the doctor decides whether the patient needs a walker, brace, cane, or other device, and should make sure that the patient can climb stairs. Also, the doctor should emphasize the life-long importance of preventing infection and give the patient written instructions about how to prevent and recognize infection, as well as what steps to take if infection does develop.

Risks

The major risks associated with limb salvage are: superficial or deep infection at the site of the surgery; loosening, shifting, or breakage of implants; rapid loss of blood flow or sensation in the affected limb; and severe blood loss and anemia from the surgery.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Limb salvage surgery is performed in a hospital setting by experienced orthopedic surgeons with demonstrated expertise in limb salvage.

Postoperative infection is a serious problem. Chemotherapy or radiation can weaken the immune system, and extensive bone damage can occur before the infection is identified. Tissue may die (necrosis) if the surgeon used a large piece of tissue (flap) to close the wound. This is most likely to occur if the surgical site was treated with radiation before the operation. Treatment for postoperative infection involves removing the graft or implant, inserting drains at the infected site, and giving the patient oral or intravenous (IV) antibiotic therapy for as long as 12 months. Doctors may have to amputate the affected limb.

Normal results

A patient who has had limb salvage surgery will remain disease-free as long as a patient whose affected extremity has been amputated.

Salvaged limbs always function better than artificial ones. However, it takes a year for patients to learn to walk again following lower-extremity limb salvage, and patients who have undergone upper-extremity salvage must master new ways of using the affected arm or hand.

Successful surgery reduces the frequency and severity of patient falls and fractures that often result from disease-related changes in bone. Although successful surgery results in limbs that look and function very much like normal, healthy limbs, it is not unusual for patients to feel that their appearance has changed.

Some patients may also need additional surgery within five years of the first operation.

Morbidity and mortality rates

Orthopedic oncologists recognize that an operation to remove a tumor that spares the limb is associated with an incidence of tumor recurrence higher than that following an amputation. However, because there is no significant difference in overall survival rates, the increased rate of recurrence in patients who undergo limb salvage surgery is considered acceptable.

QUESTIONS TO ASK THE DOCTOR

• What are the possible complications involved in limb salvage surgery?
• How do I prepare for surgery?
• What type of anesthesia will be used?
• How is the surgery performed?
• How long will I be in the hospital?
• How much limb salvage surgery do you perform in a year?
• Why do you think limb salvage will be successful in my case?
• How will I look and feel after the operation?
• Will I be able to enjoy my favorite sports and other activities after the operation?

Alternatives

If the cancer’s location makes it impossible to remove the malignancy without damaging or removing vital organs, essential nerves, or key blood vessels, or if it is impossible to reconstruct a limb that will function satisfactorily, salvage surgery may not be an appropriate treatment and amputation of the limb becomes the only alternative treatment.

Resources

BOOKS

Brown, K., ed. Complications of Limb Salvage: Prevention Management and Outcome UK: International Society of Limb Salvage, 1991.

Lerner, A., et al. Severe Injuries to the Limbs: Staged Treatment 1st ed. New York: Springer, 2007.

Malawer, Martin M., and Paul H. Sugarbaker. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases 1st ed. New York: Springer, 2001.

Sidawy, Anton N. Diabetic Foot: Lower Extremity Arterial Disease and Limb Salvage 2nd ed. New York: Lippincott Williams & Wilkins 2005.

Yarbro, Connie Henke, et al. Cancer Nursing 5th ed. Sudbury, MA: Jones and Bartlett, 2000.

PERIODICALS

Nehler, M. R., Hiatt, W. R., and L. M. Taylor Jr. “Is revascularization and limb salvage always the best treatment for critical limb ischemia?” Journal of Vascular Surgery 37 (March 2003): 704–708.

Neville, R. F. “Diabetic revascularization: Improving limb salvage in the absence of autogenous vein.” Seminars in Vascular Surgery 16 (March 2003): 19–26.

Plotz, W., Rechl, H., Burgkart, R., Messmer, C., Schelter, R., Hipp, E., and R. Gradinger. “Limb salvage with tumor endoprostheses for malignant tumors of the knee.” Clinical Orthopaedics 405 (December 2002): 207–215.

Tefera, G., Turnipseed, W., and T. Tanke. “Limb salvage angioplasty in poor surgical candidates.” Vascular and Endovascular Surgery 37 (March-April 2003): 99–104.

Teodorescu, V. J., Chun, J. K., Morrisey, N. J., Faries, P. L., Hollier, L. H., and M. L. Marin. “Radial artery flow-through graft: A new conduit for limb salvage.” Journal of Vascular Surgery 37 (April 2003): 816–820.

van Etten, B., van Geel, A. N., de Wilt, J. H., and A. M. Eggermont. “Fifty tumor necrosis factor-based isolated limb perfusions for limb salvage in patients older than 75 years with limb-threatening soft tissue sarcomas and other extremity tumors.” Annals of Surgical Oncology 10 (January-February 2003): 32–37.

ORGANIZATIONS

American Academy of Orthopaedic Surgeons (AAOS). 6300 North River Road, Rosemont, Illinois 60018-4262. (847) 823-7186. www.aaos.org

American Diabetes Association (ADA). 1701 North Beauregard Street, Alexandria, VA 22311. (800) DIABETES. www.diabetes.org.

International Society of Limb Salvage (ISOLS). E-mail: [email protected] (UK). www.isols.org.

OTHER

“Adult Soft Tissue Sarcoma.” CancerNet 2000.[cited July 11, 2001]. www.cancernet.nci.nih.gov

“Bone Cancer.” CancerNet 2000. [cited July 11, 2001]. www.cancernet.nci.nih.gov

“Bone Cancer.” ACS Cancer Resource Center American Cancer Society. 2006. [cited February, 2008]. http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_Is_bone_cancer_2.asp?sitearea=CRI

“Limb salvage after osteosarcoma resection.” AAOS On-Line Service April 1997 Bulletin http://www2.aaos.org/aaos/archives/bulletin/apr97/temple.htm

Limb Salvage Center. www.limbsalvagecentre.com/.

Maureen Haggerty

Monique Laberge, PhD

Laura Jean Cataldo, RN, EdD

Limb salvage

Definition

Limb salvage surgery is a type of surgery primarily performed to remove bone and soft-tissue cancers occurring in limbs in order to avoid amputation .

Purpose

Limb salvage surgery is performed to remove cancer and avoid amputation, while preserving the patient's appearance and the greatest possible degree of function in the affected limb. The procedure is most commonly performed for bone tumors and bone sarcomas, but is also performed for soft tissue sarcomas affecting the extremities. This complex alternative to amputation is used to cure cancers that are slow to spread from the limb where they originate to other parts of the body, or that have not yet invaded soft tissue.

Twenty years ago, the standard of care for a patient with a cancer in a limb was to amputate the affected extremity. Limb salvage surgery was an exception to the rule. Today, it is the exception that a patient loses a limb as part of cancer treatment. This is due to improvements in surgical technique, both resection and reconstruction, imaging methods (computed tomography [CT scan] and magnetic resonance imaging [MRI]), and survival rates of patients treated with chemotherapy.

In recent years, limb salvage has been extended more and more to patients severely affected by chronic degenerative bone and joint diseases, such as rheumatoid arthritis, or those facing diabetic limb amputation or acute and chronic limb wounds.

Demographics

According to the National Cancer Institute, primary bone cancer is rare, with only 2,500 new cases diagnosed each year in the United States. More commonly, bones are the site of tumors that result from the spread of other primary cancers—that is, from cancers that spread other organs, such as the breasts, lungs, and prostate. Bone cancers occur more frequently in children and young adults.

Description

Also called limb-sparing surgery, limb salvage involves removing the cancer and about an inch of healthy tissue surrounding it. In addition, if had been removed, the removed bone is replaced. The replacement can be made with synthetic metal rods or plates (prostheses), pieces of bone (grafts) taken from the patient's own body (autologous transplant), or pieces of bone removed from a donor body (cadaver) and frozen until needed for transplant (allograft). In time, transplanted bone grows into the patient's remaining bone. Chemotherapy, radiation, or a combination of both treatments may be used to shrink the tumor before surgery is performed.

Limb salvage is performed in three stages. Surgeons remove the cancer and a margin of healthy tissue, implant a prosthesis or bone graft (when necessary), and close the wound by transferring soft tissue and muscle from other parts of the patient's body to the surgical site. This treatment cures some cancers as successfully as amputation.

Surgical techniques

bone tumors. Surgeons remove the malignant lesion and a cuff of normal tissue (wide excision) to cure low-grade tumors of bone or its components. To cure high-grade tumors, they also remove muscle, bone, and other tissues affected by the tumor (radical resection).

soft tissue sarcomas. Surgeons use limb-sparing surgery to treat about 80% of soft tissue sarcomas affecting extremities. The surgery removes the tumor, lymph nodes, or tissues to which the cancer has spread, and at least 1 in (2.54 cm) of healthy tissue on all sides of the tumor.

Radiation and/or chemotherapy may be administered before or after the operation. Radiation may also be administered during the operation by placing a special applicator against the surface from which the tumor has just been removed, and inserting tubes containing radioactive pellets at the site of the tumor. These tubes remain in place during the operation and are removed several days later.

To treat a soft tissue sarcoma that has spread to the patient's lung, the doctor may remove the original tumor, administer radiation or chemotherapy treatments to shrink the lung tumor, and surgically remove the lung tumor.

Diagnosis/Preparation

Before deciding that limb salvage is appropriate for a particular patient, the treating doctor considers what type of cancer the patient has, the size and location of the tumor, how the illness has progressed, and the patient's age and general health.

After determining that limb salvage is appropriate for a particular patient, the doctor makes sure that the patient understands what the outcome of surgery is likely to be, that the implant may fail, and that additional surgery—even amputation—may be necessary.

Physical and occupational therapists help prepare the patient for surgery by introducing the muscle-strengthening, ambulation (walking), and range of motion (ROM) exercises the patient will begin performing right after the operation.

Aftercare

During the five to 10 days the patient remains in the hospital following surgery, nurses monitor sensation and blood flow in the affected extremity and watch for signs that the patient may be developing pneumonia, pulmonary embolism, or deep-vein thrombosis.

The doctor prescribes broad-spectrum antibiotics for at least the first 48 hours after the operation and often prescribes medication (prophylactic anticoagulants) and antiembolism stockings to prevent blood clots. A drainage tube placed in the wound for the first 24–48 hours prevents blood (hematoma) and fluid (seroma) from accumulating at the surgical site. As postoperative pain becomes less intense, mild narcotics or anti-inflammatory medications replace the epidural catheter or patient-controlled analgesic pump used to relieve pain immediately after the operation.

Exercise intervention

Limb salvage requires extensive surgical incisions, and patients who have these operations need extensive rehabilitation. The amount of bone removed and the type of reconstruction performed dictate how soon and how much the patient can exercise , but most patients begin muscle-strengthening, continuous passive motion (CPM), and ROM exercises the day after the operation and continue them for the next 12 months.

A patient who has had upper-limb surgery can use the opposite side of the body to perform hand and shoulder exercises. Patients should not do active elbow or shoulder exercises for two to eight weeks after having surgery involving the bone between the shoulder and elbow (humerus). Rehabilitation following lower-extremity limb salvage focuses on strengthening the muscles that straighten the legs (quadriceps), maintaining muscle tone, and gradually increasing weight-bearing so that the patient is able to stand on the affected limb within three months of the operation. A patient who has had lower-extremity surgery may have to learn a new way of walking (gait retraining) or wear a lift in one shoe.

Goals of rehabilitation

Physical and occupational therapy regimens are designed to help the patient move freely, function independently, and accept changes in body image. Even patients who look the same after surgery as they did previously may feel that the operation has altered their appearance.

Before a patient goes home from the hospital or rehabilitation center, the doctor decides whether the patient needs a walker, brace, cane, or other device, and should make sure that the patient can climb stairs. Also, the doctor should emphasize the life-long importance of preventing infection and give the patient written instructions about how to prevent and recognize infection, as well as what steps to take if infection does develop.

Risks

The major risks associated with limb salvage are: superficial or deep infection at the site of the surgery; loosening, shifting, or breakage of implants; rapid loss of blood flow or sensation in the affected limb; and severe blood loss and anemia from the surgery.

Postoperative infection is a serious problem. Chemotherapy or radiation can weaken the immune system, and extensive bone damage can occur before the infection is identified. Tissue may die (necrosis) if the surgeon used a large piece of tissue (flap) to close the wound. This is most likely to occur if the surgical site was treated with radiation before the operation. Treatment for postoperative infection involves removing the graft or implant, inserting drains at the infected site, and giving the patient oral or intravenous (IV) antibiotic therapy for as long as 12 months. Doctors may have to amputate the affected limb.

Normal results

A patient who has had limb salvage surgery will remain disease-free as long as a patient whose affected extremity has been amputated.

Salvaged limbs always function better than artificial ones. However, it takes a year for patients to learn to walk again following lower-extremity limb salvage, and patients who have undergone upper-extremity salvage must master new ways of using the affected arm or hand.

Successful surgery reduces the frequency and severity of patient falls and fractures that often result from disease-related changes in bone. Although successful surgery results in limbs that look and function very much like normal, healthy limbs, it is not unusual for patients to feel that their appearance has changed.

Some patients may also need additional surgery within five years of the first operation.

Morbidity and mortality rates

Orthopedic oncologists recognize that an operation to remove a tumor that spares the limb is associated with an incidence of tumor recurrence higher than that following an amputation. However, because there is no significant difference in overall survival rates, the increased rate of recurrence in patients who undergo limb salvage surgery is considered acceptable.

Alternatives

If the cancer's location makes it impossible to remove the malignancy without damaging or removing vital organs, essential nerves, or key blood vessels, or if it is impossible to reconstruct a limb that will function satisfactorily, salvage surgery may not be an appropriate treatment and amputation of the limb becomes the only alternative treatment.

See also Amputation.

Resources

books

Brown, K., ed. Complications of Limb Salvage: Prevention Management and Outcome. UK: International Society of Limb Salvage, 1991.

Greenhalgh, R. M. and C.W. Jamieson. Limb Salvage and Amputation for Vascular Disease. Philadelphia: W. B. Saunders Co., 1988.

Groenwald, Susan L., et al., eds. Cancer Nursing, 4th ed. Sudbury, MA: Jones and Bartlett, 1997.

periodicals

Nehler, M. R., Hiatt, W. R., and L. M. Taylor Jr. "Is revascularization and limb salvage always the best treatment for critical limb ischemia?" Journal of Vascular Surgery 37 (March 2003): 704–708.

Neville, R. F. "Diabetic revascularization: Improving limb salvage in the absence of autogenous vein." Seminars in Vascular Surgery 16 (March 2003): 19-26.

Plotz, W., Rechl, H., Burgkart, R., Messmer, C., Schelter, R., Hipp, E., and R. Gradinger. "Limb salvage with tumor endoprostheses for malignant tumors of the knee." Clinical Orthopedics 405 (December 2002): 207-215.

Tefera, G., Turnipseed, W., and T. Tanke. "Limb salvage angioplasty in poor surgical candidates." Vascular and Endovascular Surgery 37 (March-April 2003): 99–104.

Teodorescu, V. J., Chun, J. K., Morrisey, N. J., Faries, P. L., Hollier, L. H., and M. L. Marin. "Radial artery flow-through graft: A new conduit for limb salvage." Journal of Vascular Surgery 37 (April 2003): 816-820.

van Etten, B., van Geel, A. N., de Wilt, J. H., and A. M. Eggermont. "Fifty tumor necrosis factor-based isolated limb perfusions for limb salvage in patients older than 75 years with limb-threatening soft tissue sarcomas and other extremity tumors." Annals of Surgical Oncology 10 (January-February 2003): 32-37.

organizations

American Academy of Orthopedic Surgeons (AAOS). 6300 North River Road, Rosemont, Illinois 60018-4262. (847) 823-7186. <www.aaos.org>

American Diabetes Association (ADA). 1701 North Beauregard Street, Alexandria, VA 22311. (800) DIABETES <www.diabetes.org>.

International Society of Limb Salvage (ISOLS). E-mail: rjesus [email protected] (UK) <www.isols.org>.

other

"Adult Soft Tissue Sarcoma." "Bone Cancer." CancerNet 2000. [cited July 11, 2001] <www.cancernet.nci.nih.gov>.

"Bone Cancer." ACS Cancer Resource Center American Cancer Society. 2000. [cited July 11, 2001] <www3.cancer.org>.

"Limb salvage after osteosarcoma resection." AAOS. <www.aaos.org/wordhtml/bulletin/apr97/temple.htm>.

Limb Salvage Center. <www.limbsalvagecentre.com/>.

Maureen Haggerty
Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Limb salvage surgery is performed in a hospital setting by experienced orthopedic surgeons with demonstrated expertise in limb salvage.

QUESTIONS TO ASK THE DOCTOR

• What are the possible complications involved in limb salvage surgery?
• How do I prepare for surgery?
• What type of anesthesia will be used?
• How is the surgery performed?
• How long will I be in the hospital?
• How much limb salvage surgery do you perform in a year?
• Why do you think limb salvage will be successful in my case?
• How will I look and feel after the operation?
• Will I be able to enjoy my favorite sports and other activities after the operation?

Limb salvage

Definition

Limb salvage is a type of surgery that removes a cancerous tumor or lesion while preserving the nearby muscles, tendons, and blood vessels.

Purpose

Doctors perform limb salvage to remove cancer and avoid amputation , while preserving the patient's appearance and the greatest possible degree of function in the affected limb. The procedure is most commonly performed for bone tumors and bone sarcomas , but is also commonly performed for soft tissue sarcomas affecting the extremities.

This complex alternative to amputation is used to cure cancers that are slow to spread from the limb where they originate to other parts of the body, or that have not invaded soft tissue.

Precautions

Limb salvage should only be performed by experienced surgeons with specialized expertise. It should also be limited to cases in which the surgery would restore more and longer-lasting function than could be achieved by amputating the affected limb and fitting the patient with an artificial replacement (prosthesis).

If the cancer's location makes it impossible to remove the malignancy without damaging or removing vital organs, essential nerves, key blood vessels, or if it is impossible to reconstruct a limb that will function satisfactorily, salvage surgery may not be an appropriate treatment.

Biopsy is a critical component of limb-salvage surgery. A poorly planned or improperly performed biopsy can limit the patient's surgical options and make amputation unavoidable.

Description

Also called limb-sparing surgery, limb salvage involves removing the cancer and about an inch of healthy tissue surrounding it, and, if bone was removed, replacing the removed bone. The replacement can take the form of synthetic metal rods or plates (prostheses), pieces of bone (grafts) taken from the patient's own body (autologous transplant), or pieces of bone removed from a donor body (cadaver) and frozen until needed for transplant (allograft). In time, transplanted bone grows into the patient's remaining bone. Chemotherapy , radiation, or a combination of both treatments may be used to shrink the tumor before surgery is performed.

Stages of surgery

Limb salvage is performed in three parts. Doctors remove the cancer and a margin of healthy tissue, implant a prosthesis or bone graft (when necessary), and close the wound by transferring soft tissue and muscle from other parts of the patient's body to the surgical site. This treatment cures some cancers as successfully as amputation.

Surgical techniques

BONE TUMORS. Doctors remove the malignant lesion and a cuff of normal tissue (wide excision) to cure low-grade tumors of bone or its components. To cure high-grade tumors, they also remove muscle, bone, and other tissues affected by the tumor (radical resection).

SOFT TISSUE SARCOMAS.

Doctors use limb-sparing surgery to treat about 80% of soft tissue sarcomas affecting extremities. The surgery removes the tumor, lymph nodes or tissues to which the cancer has spread, and at least one inch of healthy tissue on all sides of the tumor.

Radiation and/or chemotherapy may be administered before or after the operation. Radiation may also be administered during the operation by placing a special applicator against the surface from which the tumor has just been removed, and inserting tubes containing radioactive pellets at the site of the tumor. These tubes remain in place during the operation and are removed several days later.

To treat a soft tissue sarcoma that has spread to the patient's lung, the doctor may remove the original tumor, administer radiation or chemotherapy treatments to shrink the lung tumor, and surgically remove the lung tumor.

Limb salvage for children

Doctors use expandable prostheses to perform limb-salvage surgery on children who have not stopped growing (skeletal immaturity). These children may need as many as four additional operations, at intervals of six to 12 months, to expand the prostheses as their limbs lengthen.

Because expandable prostheses have been available only since the 1980s, the long-term effects of using them are unknown.

Preparation

Before deciding that limb salvage is appropriate for a particular patient, the doctor considers what type of cancer the patient has, the size and location of the tumor, how the illness has progressed, and the patient's age and general health.

After determining that limb salvage is appropriate for a particular patient, the doctor makes sure that the patient understands what the outcome of surgery is likely to be, that the implant may fail, and that additional surgery —even amputation— may be necessary.

Preoperative rehabilitation

Physical and occupational therapists help prepare the patient for surgery by introducing the muscle-strengthening, ambulation, and range of motion (ROM) exercises the patient will begin performing right after the operation.

Aftercare

During the five to ten days the patient remains in the hospital following surgery, nurses monitor sensation and blood flow in the affected extremity and watch for signs that the patient may be developing pneumonia , pulmonary embolism, or deep-vein thrombosis.

The doctor prescribes broad-spectrum antibiotics for at least the first 48 hours after the operation and often prescribes medication (prophylactic anticoagulants) and antiembolism stockings to prevent blood clots. A drainage tube placed in the wound for the first 24-48 hours prevents blood (hematoma) and fluid (seroma) from accumulating at the surgical site. As postoperative pain becomes less intense, mild narcotics or anti-inflammatory medications replace the epidural catheter or patient-controlled analgesic pump used to relieve pain immediately after the operation.

Exercise intervention

Limb salvage requires extensive surgical incisions, and patients who have these operations need extensive rehabilitation. The amount of bone removed and the type of reconstruction performed dictate how soon and how much the patient can exercise, but most patients begin muscle-strengthening, continuous passive motion (CPM), and ROM exercises the day after the operation and continue them for the next 12 months.

A patient who has had upper-limb surgery can use the opposite side of the body to perform hand and shoulder exercises. Patients should not do active elbow or shoulder exercises for two to eight weeks after having surgery involving the bone between the shoulder and elbow (humerus). Rehabilitation following lower-extremity limb salvage focuses on strengthening the muscles that straighten the legs (quadriceps), maintaining muscle tone, and gradually increasing weight-bearing so that the patient is able to stand on the affected limb within three months of the operation. A patient who has had lower-extremity surgery may have to learn a new way of walking (gait retraining) or wear a lift in one shoe.

Goals of rehabilitation

Physical and occupational therapy regimens are designed to help the patient move freely, function independently, and accept changes in body image . Even patients who look the way they did before surgery are likely to feel that the operation has altered their appearance.

Before a patient goes home from the hospital or rehabilitation center, the doctor decides whether the patient needs a walker, brace, cane, or other device, and should make sure that the patient can climb stairs. Also, the doctor should emphasize the life-long importance of preventing infection and give the patient written instructions about how to prevent infection and what to do if infection does develop.

Risks

The major risks associated with limb salvage are: superficial or deep infection at the site of the surgery; loosening, shifting, or breakage of implants; rapid loss of blood flow or sensation in the affected limb; and severe blood loss and anemia from the surgery.

Postoperative infection is a serious problem. Chemotherapy or radiation can weaken the immune system, and extensive bone damage can occur before the infection is identified. Tissue may die (necrosis) if the surgeon used a large piece of tissue (flap) to close the wound. This is most likely to occur if the surgical site was treated with radiation before the operation. Treatment for postoperative infection involves removing the graft or implant, inserting drains at the infected site, and giving the patient oral or intravenous antibiotic therapy for as long as 12 months. Doctors may have to amputate the affected limb.

Normal results

A patient who has had limb-sparing surgery will remain disease-free as long as a patient whose affected extremity has been amputated.

Salvaged limbs always function better than artificial ones. However, it takes a year for patients to learn to walk again following lower-extremity limb salvage, and patients who have undergone upper-extremity salvage must master new ways of using the affected arm or hand.

Successful surgery reduces the frequency and severity of patient falls and of the fractures that often result from disease-related changes in bone. Although successful surgery results in limbs that look and function very much like normal, healthy limbs, it is not unusual for patients to feel that their appearance has changed.

Abnormal results

Some patients will need additional surgery within five years of the first operation. Some will eventually require amputation.

Post-operation directives from the patient's physician may include the following items:

• Patients may be told that they should never jog, lift heavy objects, or play racquet sports.
• Wearing a splint or cast can damage nerves and veins in the affected limb.
• Implants can loosen, shift to a new position, or break.

See Also Chondrosarcoma; Ewing's sarcoma; Osteosarcoma

Resources

BOOKS

Groenwald, Susan L., et al., eds. Cancer Nursing, 4th ed. Sudbury, MA: Jones and Bartlett, 1997.

Ignatavicius, Donna D., et al. Medical-Surgical Nursing Across the Health Care Continuum, 3rd ed. Philadelphia: W. B.Saunders Company, 1999.

OTHER

"Adult Soft Tissue Sarcoma." "Bone Cancer." CancerNet 2000.11 July 2001 <http://www.cancernet.nci.nih.gov>.

"Bone Cancer." ACS Cancer Resource Center American Cancer Society. 2000. 11 July 2001 <http://www3.cancer.org>.

"Sarcoma." ACS Cancer Resource Center American Cancer Society. 22 March 2000. 11 July 2001 <http://www3.cancer.org>

"Soft-Tissue Sarcoma." Memorial Sloan-Kettering Cancer Center 2001. 11 July 2001 <http://www.mskcc.org/>.

Maureen Haggerty

QUESTIONS TO ASK THE DOCTOR

• Why do you think limb salvage will be successful in my case?
• How will I look and feel after the operation?
• Will I be able to enjoy my favorite sports and other activities after the operation?