Limb salvage is a surgical procedure to save a limb (usually one of the lower extremities) that is at high risk of amputation. The need for limb salvage can result from several different underlying causes, including various types of trauma, diabetes, vascular disease, cancer, or neuropathy.
The primary goal of limb salvage is to maintain or restore a person’s stability as well as the ability to walk. The exact method of intervention may differ considerably depending on the underlying cause of the potential loss of a limb, the severity of the causative condition, and other factors.
There are many different medical conditions that can result in the need for limb salvage. These may include:
The primary aim of limb salvage in a person with bone cancer is to remove a tumor with minimal complications and perform reconstructive surgery, when necessary, to maintain the appearance, durability, and functionality of the limb.
Saving a limb that has been impacted by bone cancer can be challenging, depending on many factors, such as:
- How the tumor responds to chemotherapy, radiation therapy, or other interventions aimed at shrinking the tumor
- The size of the tumor
- Whether the tumor has spread to nearby tissues
- How much bone tissue must be removed to eliminate a high risk for metastasis (secondary tumors growing away from the site)
- If a bone graft is needed
Once the tumor has been reduced in size and surgically removed, reconstructive limb salvage surgery can begin.
Limb salvage and reconstructive surgery can include:
- Reconnecting blood vessels
- Replacing major blood vessels
- Replacing muscles that have been removed (due to cancer)
Nerve grafts (the repair of damaged nerves) may also be needed in areas affected by the tumor growth. But one of the biggest challenges in limb salvage surgery to patients who have had bone cancer is the lack of available bone for reconstruction.
Reconstruction of missing bone may include using:
- Endoprosthesis: Surgically inserting an artificial device to replace bone that was removed due to cancer
- Allograft bone: Using preserved bones that have come from a deceased donor
- Tissue regeneration: The process of renewal, growth, and repair of tissue that was damaged by the tumor
Innovative tissue regeneration treatments are emerging in the medical field. Tissue regeneration combines a person’s own cells with synthetic matrix materials and protein growth factors to help regenerate a person’s tissue.
Neuropathy, particularly diabetic neuropathy (nerve damage caused by diabetes), often leads to the need for amputation of a limb (usually a leg). Amputation becomes necessary because of a sequence of events, including:
- High blood glucose (sugar) levels, which lead to nerve damage
- Nerve damage that lowers a person’s sensation in the limbs, usually starting in the feet
- A lack of sensation in the lower extremities causing unnoticed injuries that can lead to skin ulcers or infections
- Poor wound healing
Once an infection gets started in the foot, it often progresses and may require a surgical procedure to remove the infected area. In a worst-case scenario, amputation is needed unless the limb can be salvaged.
Peripheral Artery Disease (PAD)
Peripheral artery disease (PAD) causes a reduction in blood flow to the limbs, usually occurring in the legs. The reduced blood flow caused by PAD can progress to a condition called critical limb ischemia (CLI), which can result in poor wound healing and severe pain in the leg or foot. It can even cause gangrene.
Treatments that may need to be performed to save the limb of a person with CLI include:
- Angioplasty and stenting: A minimally invasive surgical procedure using a balloon and metal stent to keep the artery open, restoring blood flow
- Atherectomy: A minimally invasive surgical procedure used to remove plaques from the narrowed blood vessels
- Bypass: A procedure using autogenous vein tissue (tissue derived from the patient) or a synthetic tube to bypass a blocked or narrowed blood vessel, allowing blood to circulate freely and thereby delivering vital oxygen and nutrients to the ischemic area
A trophic ulcer is a lesion on the skin caused by external trauma and may result from:
- Vascular insufficiency (poor circulation)
- Loss of sensory nerve fibers
When limb salvage is needed to treat a trophic ulcer, it may involve providing a stable walking surface (particularly when necrotic foot ulcerations are present).
Critical Limb Ischemia
Critical limb ischemia (CLI) is considered a syndrome (a set of associated symptoms) caused by ischemia (inadequate blood supply to part of the body, which results in lack of proper oxygenation). Peripheral artery disease is a common condition that may cause critical limb ischemia.
CLI may cause symptoms including:
- Tissue loss
- Ulcers that will not heal properly
CLI creates a very high risk of losing a limb. The primary goal of limb salvage surgery for critical limb ischemia is to restore blood flow to the affected area using minimally invasive endovascular techniques (performed inside the blood vessel) or an open method of vascular surgery.
The decision to save a critically injured limb usually involves a multidisciplinary team of healthcare professionals who consider many different factors when deciding on a treatment plan.
There is a wide range of specialists who may be involved in limb salvage, including:
- Foot and ankle surgeons: Responsible for removing infected tissue, when applicable, and performing reconstructive surgery when lower extremity deformities are present
- Orthopedic specialty surgeons: Surgeons who specialize in the musculoskeletal system and may need to perform implant surgery to replace bone
- Vascular surgeons: Subspecialty surgeons who perform procedures such as endovascular surgery (like angioplasty) to help promote the healing of wounds and surgical sites by improving blood flow
- Infectious disease specialists: Manage treatment such as the administration of microbial therapy
- Internal medicine doctors: Manage underlying medical conditions that can contribute to a high risk of amputation, such as diabetes, kidney disease, or heart disease
- Endocrinologists: Specialize in the treatment of diabetes and help patients maintain normal blood glucose levels, which promotes wound healing
- Plastic surgeons: Perform specialized reconstructive surgery for large wounds or tissue defects in complex wounds (such as severe combat wounds)
- Occupational therapists and physical therapists: Help patients regain as much function as possible after surgery
When it comes to long-term expense, some sources report that limb salvage is more cost-effective than having an amputation. But regardless of the long-term cost savings to the patient, limb salvage surgery is more expensive to perform than amputation and may not be covered by health insurance.
A 2018 study found that patients considered having low income were more likely to undergo an amputation than those not considered of low income and having good insurance coverage.
In another study, monetary losses were incurred by 10 U.S. medical facilities that performed arterial reconstructive limb salvage procedures on 566 people with Medicare insurance coverage.
While limb salvage can be cost-effective in the long run, it’s important to check with your insurance provider to make sure that your surgery will be covered.
The outcome for limb salvage differs based on the reason for the surgery.
Limb salvage does not impact the survival rate in those with a specific type of cancer called limb sarcoma. It is the primary treatment choice—over amputation—in 95% of the cases.
Bone Cancer in Children
Bone sarcoma—a group of cancers that affects the bone and connective tissue—in small children can interrupt the child’s normal growth. This is particularly true when the tumor is around the knee, where it can interfere with critical growth plates in the lower limb.
A 2020 study involved 45 children with bone sarcoma of the knee area who underwent limb salvage surgery involving endoprosthesis, an artificial device to replace the missing body part.
The survival rate and functional outcomes (including the impact on growth) were recorded. At the five-year mark after surgery, the overall survival rate was 72.7% and the cancer-free survival rate was 54.9%.
When the limbs were measured at the five-year mark, 20 patients were discovered to have limb length discrepancies within just 2 centimeters (0.79 inches). The children were found to have good functional results as well.
Peripheral Artery Disease (PAD)
A 2014 study aimed at evaluating the success and outcome of 202 people who underwent PAD in 229 limbs.
Surgical procedures to obtain the goal of limb salvage included:
- Endovascular surgery
- Angioplasty revascularization
- Bypass surgery
Endovascular surgery was implemented as the initial plan of treatment in 198 limbs. A total of 31 study participants underwent bypass surgery and another 16 had failed endovascular intervention that resulted in bypass surgery.
The study results revealed that the amputation-free survival rates were 75.5% at one year and 57.6% at two years. The study concluded that the first approach, minimally invasive endovascular surgical methods, including angioplasty, for PAD, can result in a satisfactory limb salvage rate.
Limb Salvage for Acute Limb Ischemia Due to Trauma
Trauma that causes vascular injury, can lead to acute limb ischemia (ALI), a rapid decrease in lower limb blood flow due to an obstruction of an artery, which is an emergency situation.
A 2020 study looked at the outcome of limb salvage in those who underwent revascularization for traumatic ALI. Although there was a very high rate of limb salvage procedures performed, good functional outcomes were not attained.
Outcomes included regaining function, such as being able to stand or walk on the salvaged limb after surgery. This means that the complex injuries in those who underwent limb salvage for trauma contributed to a loss of functionality of the salvaged limb. This was particularly true for trauma patients undergoing multiple operations.
A Word From Get Meds Info
Undergoing limb salvage surgery can present a major crossroads in a person’s life. Before undergoing any procedure, it’s important to do your research about the surgical process and the medical terminology involved, as well as all available treatment options.