Limb Preservation Surgery

The future of limb preservation surgery is very bright.; New cutting edge technology is currently undergoing investigation that will lead to dramatic changes in our approach to the maximization of extremity function and preservation of the patient’s quality of life. The treatment for patients experiencing significant soft tissue and/or bone is highly complex. The most common causes for the need for limb preservation surgery are: bone & soft tissue tumors, complications from total joint replacement, bone & soft tissue infections and high energy trauma.

Complications from total joint replacement surgery may be devastating. Common causes include loosening, infection and periprosthetic fracture. It is essential that these types of problems be managed by a surgeon familiar with revision reconstructive techniques. This may involve special joint implants, allografts, acetabular cages or cable techniques. Infection can also lead to extensive morbidity and disability. It is important to treat such infections be treated early and aggressively, in order to retain as much function of the extremity as possible. Many of the techniques from oncologic surgery are helpful in developing a treatment plan to salvage patient’s total joints with excessive bone loss.

The diagnosis and management of bone and soft tissue tumors requires the supervision of an experienced team of diagnosticians, surgeons, and medical/ radiation oncology specialists. The incidence of bone and soft tissue sarcomas is a small fraction of that of breast, prostate and lung cancers. This rarity makes it essential that highly trained specialists manage these tumors with experience in the care of patients afflicted with these tumors. At the University of Alabama at Birmingham University Hospital, a group of consultants, each nationally renowned in their trained field, meet weekly to discuss the plan for diagnosis and treatment of patients with bone and soft tissue tumors. Our goal is to optimize the patient’s outcome, in terms of cancer cure and functional abilities. The Center for Musculoskeletal Oncology (CMO) at UAB is composed of physicians in the fields of orthopedic surgery, radiology, pathology, radiation oncology, and medical oncology.

Over the past decade, we have made great strides in the early detection, diagnosis and treatment of many bone and soft tissue tumors. With advancements in imaging, chemotherapy, radiotherapy and surgical techniques, the future looks very bright.” Since the 1970s, the life expectancy of patients with osteosarcoma, a highly malignant form of bone cancer, has improved from less than 20 percent survival at five years to over 80 percent. As the molecular basis for more tumor is identified, we can one day target malignant cells specifically without the harmful effects to normal tissue. Advancements in radiation therapy have also made an impact on the local control of soft tissue tumors. By placing brachycatheters during surgery, we can localize radiation to the tumor bed, over a short period of time. This can limit the radiation exposure of the surrounding normal tissue that can sometimes be harmed by wide-field external beam.

In the past three decades, there have been substantial improvements in the disease outcomes of patients with a variety of musculoskeletal sarcomas. Twenty to thirty years ago, a patient with a high-grade bone sarcoma, such as an osteosarcoma or a Ewing sarcoma, had a 10-20% chance of surviving for five years. In most instances, the only form of local control of the tumor was an amputation. Today, as a result of advances in surgical and adjuvant chemotherapy, a patient who has osteosarcoma or Ewing sarcoma without metastasis at the time of diagnosis has a 75% chance of surviving for five years or more. Likewise, the vast majority of patients are being treated with limb preservation techniques.

The reconstruction options now include the use of allografts, metallic prostheses, and at times composites of both. These advances have been universally heralded as functionally beneficial to patients, however actual studies comparing the results of limb salvage with those of amputation, or assessing the differences in outcomes among the various types of prostheses, have only recently been reported. Although difficult to assess function, quality of life, and patient acceptance, we are beginning to understand the beneficial long-term outcomes of these limb salvage procedures.

Predicting psychological outcomes is very difficult. Patients who have a good functional outcome after limb salvage generally are satisfied, but still have concerns about the durability of the reconstruction. Patients who have immediate amputation also struggle with thoughts that this might have been avoided. Despite advances in limb salvage surgery, patients are confronted with a variety of adaptive challenges related to physical, psychological, social, and vocational issues.

Clinical investigators at UAB, while employing the latest available techniques and prosthetic devices are endeavoring to assess the functional outcomes and quality of life after limb salvage and amputation following resection of bone and soft tissue sarcomas, but considerable progress still needs to be made both in reconstruction techniques and in assessing outcomes. Only a limited number of studies have directly compared one reconstruction technique with another for the same type and location of tumor, and surgeons are currently left to individualize options for a given patient after explaining the alternatives to the patient and the family. The Center for Musculoskeletal Oncology at UAB are working to develop improved outcome tools.

Dr. Siegel and his colleagues are also pursuing the understanding of musculoskeletal tumor at the molecular level. Advances in the molecular biology have provided better incite into the etiology of bone sarcomas and through this work the design of specific targets to direct therapy will be developed in the future. Thanks to significant improvements in diagnostic tools, such as CT, MRI, PET and SPECT, the enhanced ability to identify the pathologic characteristics, the improving ability to treat systemically with a variety of chemotherapies and the ability of the orthopedic oncologic surgeon to treat the primary neoplasia while maintaining functionality the oncologic team approach is pursuing the optimal outcome, and quality of life for this group of patients.