Limb Salvage Surgery

BONE SARCOMAS

There are a variety of reconstruction options after excision of bone tumours. Metallic prostheses (megaprostheses), which span the resection gap and allow for movement of the joint form the mainstay in limb salvage surgery for reconstruction after tumour resection, providing both mobility and stability. They provide an immediate return to function and unlike biologic alternatives (bone) are not affected by on-going adjuvant chemotherapy and radiotherapy. Low cost, locally manufactured prosthesis are now available and these remain the workhorse for surgeons in resource challenged settings for prosthetic reconstructions after limb salvage. These prostheses are now routinely being used even for total bone resections and total femur and total humerus replacements are not uncommon

A composite of an allograft (bone bank strut graft) and prosthesis can also be used for reconstruction in certain situations. An allograft replaces the segment of bone resected, while a prosthesis implanted in the allograft and host bone replaces the articular surface.

SOFT TISSUE SARCOMAS

Though surgical excision remains the mainstay of treatment, a vast majority of patients of soft tissue sarcoma would require radiotherapy as a component of limb salvage. Radiotherapy may be delivered either as pre or postoperative radiotherapy. Split skin grafts fare poorly when subjected to radiation and hence it is preferable to have a robust flap for soft tissue cover in case primary closure is not possible following resection. Incisions closed under tension are also liable to break down during or after radiotherapy leading to prolonged delays in wound healing with a detrimental cascading effect on the delivery of adjuvant treatment modalities. In case the underlying bone or metallic prosthesis is exposed, a flap is mandatory in order to cover it and enable early wound healing and rehabilitation.

Thus a relaxed, tension free, robust soft tissue cover is the cornerstone to ensure that heroic resections are not doomed to disaster in a milieu that is otherwise detrimental to wound healing. Patients with tumours of the lower extremity involving major neurovascular structures and for whom radiation therapy is planned have an increased risk of a nonhealing wound following resection which may necessitate a delayed local or free vascularised tissue transfer.

It has been shown that there is a tendency of higher wound complication rates in patients who are referred for late reconstruction and the early involvement of plastic surgeons can help reduce this problem.

ABOUT BONE SARCOMA

A recent report suggests that acellular dermis reconstruction offers an excellent coverage alternative after excision of cutaneous and soft tissue malignancies in patients with limited options of native tissue coverage. It serves as a bridge to permanent reconstruction or as a permanent biologic dressing of complex surgical defects. Even in situations in which adjuvant radiation was needed, AlloDerm was used without major complications. Flaps when used can be local or distant, pedicled or free, depending on the anatomic area affected and the condition of the surrounding tissues whether it has been violated by prior surgery or not

CONCLUSION

The surgeon must decide with the patient what the best surgical procedure is for that individual and he is then responsible for achieving adequate margins and reconstructing the limb if limb salvage is chosen. Properly indicated and executed limb salvage offers the advantage of better function and psychological benefits resulting in an overall improvement in quality of life. It entails a well-orchestrated effort involving various specialties and better outcomes are likely to be achieved with centralisation of expertise at regional centres so that surgeons and their teams can offer a full range of surgical options to their patients, based upon experience and knowledge. The cost of treatment can be expensive and the postoperative rehabilitation is prolonged often requiring increased inpatient hospital care. Striking the right balance between adequate resection, while yet retaining or reconstructing tissue for acceptable function and cosmesis is a difficult task and complications are not uncommon.Patients and their families need to be counselled regarding the potential setbacks that may occur in the course of their road to recovery, but the eventual satisfaction achieved by both, patient and surgeon after a successful limb salvage is unparalleled and is the elixir that drives oncology surgeons to sail into uncharted waters and to scale new heights.