Limb Salvage Surgery in Children - A Review

Introduction

Limb salvage surgery is one of the crucial surgeries performed to save the limb by selectively removing only the affected portions involved in the tumor. Usually, tumors such as osteosarcoma affect the long bones of the leg or arm. This approach has become a standard treatment with a high success rate in maintaining limb function and the patient's quality of life.

What Is Limb Salvage Surgery?

Limb salvage surgery is a surgical procedure performed to extensively resect a bone tumor or diseased bone and simultaneously restore bone and joint, making them esthetically pleasing and functional. It is part of limb salvage therapy, which also includes concomitant neoadjuvant chemotherapy, adjuvant radiotherapy, and the surgical intervention itself.

What Are the Indications of Limb Salvage Surgery?

Limb salvage surgery is indicated in various conditions:

• Bone Sarcomas: Bone and soft tissue cancers are rare tumors that spread to other body parts.

  • Osteosarcoma: This commonly affects the long bones in the arms and legs and is seen more in children in their growing years.

  • Ewing's Sarcoma: Ewing's sarcoma commonly affects the pelvis, legs, and arms and is seen more in children and young adults.

  • Rhabdomyosarcoma: Rhabdomyosarcoma is an aggressive type of cancer affecting soft tissues usually seen in children. Overall, it is a rarely occurring tumor.

• Trauma: In cases where there is severe trauma, like crush injuries and involving complicated fractures. These complications threaten limb survival, and the aim here is to preserve as much as possible by improving the patient's life.

• Infections: Severe, chronic infections that threaten limb survival may be saved to some extent by using limb salvage surgery by removing the infected part and reconstructing it using appropriate techniques. Infections such as osteomyelitis, septic arthritis, and necrotizing fascitis are common in children and are indicative of limb salvage surgery.

• Vascular Disorder: Disorders in the vasculature cause compromise in the blood flow, which can further lead to necrosis. If not treated promptly, it may lead to limb loss. In children:

  • Kawasaki Disease: This is an inflammatory condition that is known to cause vasculitis and is further complicated by forming aneurysms and stenosis in the arteries.

  • Congenital Vascular Malformations: Children who have defective blood vessels by birth may need surgical corrections to restore blood flow.

• Contraindications include:

  • Very young child.

  • When the tumor is very close to an important nerve or artery.

  • Unshrinken tumor even after chemotherapy planned before surgery.

  • Insufficient skin or tissue for reconstruction after tumor removal.

How Is the Procedure Performed?

Successful limb salvage surgery is a collaborative effort between healthcare professionals, such as pediatric surgeons, general surgeons, anesthesiologists, physical therapists, and dermatologists. The steps followed in the procedure are:

• Preoperative Preparation: A careful history and physical examination are done to assess the patient's general health.

• The type, location, size of the tumor, and extent of the metastases are noted and checked to see if it is favorable for limb salvage surgery.

• Appropriate imaging, blood tests, and biopsy were conducted to evaluate the tumor characteristics and to study the tissue in detail.

• Preoperative chemotherapy and radiation are given for a few months to kill cancer cells and shrink the tumor.

Intraoperative Care

• Principles of Resection

  • Wide Local Excision: The entire diseased, infected, or tumor region is removed along with a margin of healthy tissue to ensure no remnants of the disease remain.

  • Pathology Consult During Surgery: The excised tissues are histopathologically examined to confirm whether the margins are healthy and whether the excision can be stopped.

  • Reconstruction: After removal and confirmation, the gap is reconstructed using grafts, prostheses, implants, etc.

What Are the Types of Limb Salvage Surgery?

• Autograft or Allograft: Small tissue is replaced with autograft, which uses the patient’s bone to replace the excised area. When tissues are taken from the deceased donor, it is called an allograft. For larger defects, an allograft or prosthesis is used.

• Tumor Endoprosthesis: Custom-designed implants were used; this is the most common method. The bone graft is sized to the required size and fixed using metal rods, plates, screws, and cement. When required, the joint implant is fixed with a plate and screws. Muscles and tendons are attached to implants. The surgical site is closed with healthy soft tissue.

• Soft Tissue Reconstruction: Using skin grafts and muscle flaps to repair the soft tissues and close the wound.

Postoperative Care:

• The area is bandaged in a splint and immobilized to help heal.

• Epidural anesthesia and oral analgesics prescribed to relieve the patient’s pain are given.

• Broad-spectrum antibiotics are given to prevent infections.

• The patient is closely monitored for any signs of pulmonary embolism(sharp chest pain with shortness of breath seen) and signs of pneumonia (fever, phlegm, shortness of breath with pain).

• Physical therapy is to be started after surgery and to be continued for a year.

What Are the Special Considerations in Children?

• Limb Salvage Surgery With Epiphyseal Preservation: This technique involves preserving growth plates so that their growth is not restricted. Based on the tumor’s location, consideration is given to preserving the distal femoral growth plate and epiphysis to help restore the growth capacity to some extent.

• Extendable Tumor Endoprosthesis: This prosthesis elongates as the child grows, so repeated surgeries are unnecessary. A conventional endoprosthesis is commonly used, which is lengthened using a telescopic module. Another system is the expandable system, which lengthens the remaining bone. Both systems have motor drives that are activated by electromagnetic waves.

• Semi-joint Prosthesis Replacement: In this method, most of the natural joint is preserved, and only when necessary is that part of the joint replaced. In children younger than 11 years with osteosarcoma, this method is recommended after resecting the tumor if it is present at the distal part of the femur and proximal part of the tibia. A semi-knee prosthesis that can move biaxially helps significantly reduce metal prosthesis wear on the cartilage in these children.

What Are the Risks and Complications of Limb Salvage Surgery?

1. Superficial or deep infections.

2. Deep vein thrombosis.

3. Loosening of the prosthesis.

4. Limb length discrepancy.

5. Nonunion bone grafts.

6. Contractures (permanent tightening of joints).

7. It might require a repeat surgery and amputation.

Conclusion

Surgery replacement of diseased tissue with grafts and prosthetic implants is known as limb salvage surgery. This is indicated in children in cases of severe trauma, infections, and tumors. Careful case assessment and evaluation are necessary to reduce postoperative complications and improve the child patient's life.