Limb salvage

Overview

In order to prevent the need for an amputation, limb salvage, also known as limb-sparing, is a surgery that is used to try to spare a limb that has been damaged, either by injury or disease. People with malignant tumors from the neck to the hand and from the pelvis to the foot have benefited greatly from the surgical procedure. Occasionally, albeit not consistently, this can be achieved with minimal to no enduring issues affecting the limb’s daily functionality.

The purpose of limb salvage surgery is to improve the patient’s quality of life by restoring function and preventing complications that may arise from amputation.

Types of procedure

The restoration or replacement of significant bone loss has been one of the major concerns for surgeons. The specific treatment performed will depend on the type and location of the limb damage. There are several distinct types of limb salvage surgery. Among the common procedures used to limbs salvage are:

• Allograft bone replacement: In allograft bone replacement, bones that have been preserved from people who have passed away and given their organs and tissues are used to replace damaged bones. After receiving an allograft, the recipient’s bones will adapt to it and grow into it, partially replacing the allograft with their own bone. Since there are few pieces of the donor’s cells in the allograft to induce the reaction, bone rejection is uncommon. The bone is mostly inert on its own. The primary challenges associated with allograft reconstruction include the risk of infection, graft fracture, or unsuccessful healing between the graft and the neighboring patient’s bone. Treatment for fracture and non-union is frequently successful. Removal of the allograft is typically necessary for the treatment of an infected graft.
• Endoprosthesis: Implantable metal replacement (metal endoprostheses) have brought about a significant transformation in the realm of limb salvage. In order to reconstruct tumors, prosthetics must replace the joint surface as well as a large portion of the bone next to the joint. Prosthetics can be inserted with or without bone cement.
• Tissue regeneration: The medical field of tissue regeneration is developing rapidly. To enhance the success of limb salvage, new tissue engineering concepts are starting to be applied to reconstructive surgeries. To encourage the regeneration of a patient’s own cells, tissue engineering combines the patient’s own cells with artificial matrix components and purified protein growth factors. Additionally, utilizing the Ilizarov or spatial frame technique, bone can be moved and made to grow by one millimeter per day (or one inch per month).
• Fusion of a joint: In rare instances, the surgeon might recommend immobilizing a joint by facilitating the fusion of its ends when there is insufficient surrounding muscle to enable mobility.

Reasons for undergoing the procedure

The degree of the limb damage, the patient’s general health and medical history, and the treatment goals all play a role in determining whether or not they are a candidate for limb salvage surgery. The appropriate course of action for the particular scenario should be discussed with the healthcare provider. If limb salvage surgery is a viable option for the patient, they will be able to examine the patient’s condition and give them more information.

Risk

The strength of the muscles surrounding the neighboring joint plays a major role in how well an allografted or endoprosthetic limb functions, which can be comparable to the function of a natural limb or a conventional hip or knee replacement. There are advantages as well as disadvantages to every strategy. Allografts do have the advantage of strengthening over time and being less likely to require additional surgery. The following are possible risks of limb salvage surgery:

• Infection.
• Nonunion of an allograft (complication with union of the host bone with the donor bone).
• Allograft fracture (structural fracture).

An endoprosthesis carries a reduced risk of immediate complications, but it comes with an elevated probability of necessitating subsequent surgeries. Typically, these prostheses have a lifespan of around 15 years, occasionally less. Consequently, a younger individual undergoing such a reconstruction is highly likely to require a revision in the future. While revisions can generally be performed without compromising functional outcomes, they are expensive and best avoided if possible.

Before the procedure

The healthcare provider will speak with the patient before performing limb salvage surgery to go through the specifics of the treatment, including potential complications and aftercare instructions. Pre-operative tests to assess the heart and lungs will probably also be performed by the healthcare provider.

Two actions are required to save a limb.

• First, the healthcare provider must be sure that the tumor can be safely removed without contaminating the resection region (tumor spillage) because tumor recurrence significantly raises the risk of tumor-related death.
• Second, the healthcare provider needs a strategy for reconstruction of the limb. Utilizing MRI and CT imaging, a surgeon can formulate a comprehensive surgical plan, greatly reducing uncertainties regarding the tumor’s location and extension.
• One week before surgery, avoid aspirin and non-steroidal anti-inflammatory medications (NSAIDs).
• Avoid eating or drinking after midnight before the surgery.

Procedure

Reconstruction starts once the tumor has been removed. Major blood vessels may be reconnected or replaced as part of reconstruction. In some circumstances, it is possible to transfer muscles to replace those that have been removed. In other circumstances, cutting-edge plastic surgical techniques can be utilized to remove tissues from one location and place them in another. Nerve grafts or repairs may be carried out in some cases.

After the procedure

After surgery, most patients stay in the hospital for at least two to three days. A rehabilitation team will be available to the patient as support during that period. A physiotherapist, an occupational therapist, and a social worker will probably make up the team. Along with exercises and strategies to build muscles, their objective is to offer guidance and support.

When muscles, nerves, or bones are injured, recovery times can take weeks or even months to complete. It can take up to a year for nerve healing to take place because nerve endings grow very slowly, at a pace of roughly 1mm every day. What to expect following the procedure and throughout the recovery period will be explained in further detail by the healthcare provider.

Outcome

The type and location of the bone lesion affect the recovery time. Healing a wound typically takes two weeks. If bone healing is required, a healthcare provider might advise patients to keep the affected extremity away from powerful forces like full weight-bearing for six weeks.

After a limb salvage, many patients can resume their regular activities in four to six weeks. Driving, going back to work, and carrying out routine everyday activities around the house all fall within this category. However, it’s also crucial to let the healthcare provider know if there are any situations, like living alone, that can make rehabilitation difficult. The rehabilitation team can assist in setting up at-home care in certain situations.