limb salvage

Birth of limb salvage:

The earliest reports of limb salvage for bone sarcomas were by Eiselsberg in 1897 and Klapp in 1900. Both authors reported the successful use of bone grafts to repair large defects created by resection of the lesion. After these articles were published, there were numerous case reports, but most of the results were either inconclusive or unsuccessful.

Although there were sporadic reports of limb salvage in patients with high-grade sarcoma, the procedure was reserved generally for patients with aggressive benign lesions and low-grade malignancies. As experience in resectional surgery increased, new techniques of oncologic reconstruction were employed.

In the early 1970s successive events outside the scope of orthopedic surgery changed the course of orthopedic oncology. The introduction of computerized tomography enabled precise localization of tumors and their relationships with vital neurovascular structures, making selection of candidates for limb salvage more of a science and less of an art. The discovery that adriamycin interfered with the natural history of osteosarcoma established the role of adjuvant chemotherapy in the treatment of osteosarcoma. There was a gradual withdrawal of general surgeons from the care of patients with extremity sarcomas. With these developments came the need to develop reconstructive procedures to make the salvaged limbs more functional. This in turn spurred a relationship with the fast-emerging prosthetic industry. Towards the end of the decade, the Musculoskeletal Tumors Society (MSTS) was formed by about 20 orthopedic surgeons who first met in 1979.

The concept of limb-sparing surgery for bone sarcomas has gradually evolved over the past 25 years. Prior to this, all high grade bone sarcomas were treated by amputation.

The proportion of limb salvage operations in the treatment of primary malignant bone tumors has increased considerably and today is about 70-80%.

Credits for Successful limb salvage surgery:

Two major factors share the credit for increasing successful limb salvage surgery; it is difficult to know which is more important. The two factors are improved radiological imaging and increased effective use of adjuvant treatment both chemotherapy and irradiation.

Improvements in tumor management are the result of significant advances including improved understanding of tumor biology, effective induction (neoadjuvant) chemotherapy, advances in accurate preoperative imaging, improved surgical techniques, and technological advances in reconstructive hardware.

By 1990, most patients with an extremity sarcoma are treated with a limb salvage procedure; amputation has become almost recommended only for recurrent disease, patient with neglected tumor that has grown to huge size with infiltration of all the surrounding tissues or for patient with pathological fracture with large haematoma or patient develops infection on top of his tumor.

There are three components to limb-sparing surgery for bony sarcomas. The first is the resection of the bony tumor. The second is the reconstruction of the large bone defect. In general, this defect includes a segment of the affected bone and adjacent joint. The third component is the use of adequate soft tissue or muscle flaps, or both, to provide good soft-tissue coverage and to re-establish motor function and stability.

There are many established methods for reconstruction of the bony defect after en bloc resection of the tumor mass as the use of massive prostheses, allografts, autograft, combinations of grafts and prostheses or recently recycling of the resected tumor segment can be achieved after devitalization of the tumor cells by heating, freezing or irradiation.

The long term survival that can be achieved now with limb salvage and the fact that bone sarcoma of the extremities usually affects young healthy individuals made many orthopedic surgeons have striven for long-lasting results by means of biological reconstructive options