dr james c wittig, orthopedic oncologist, new york, new jersey
Patient Education
Limbsparing Surgery

An Orthopedic Oncologist is an orthopedic surgeon who specializes in treating bone and soft tissue tumors and sarcomas. The orthopedic oncologist is specially trained in limb sparing surgery, that is, to preserve the limb, arm or leg, instead of performing an amputation. Rarely, however, an amputation may be required to remove the tumor. Thus major amputations and stabilization procedures are also part of the specialty of orthopedic oncology.

Limb salvage or limb sparing surgery refers to surgically removing a tumor of an extremity without performing an amputation. The limb is saved. In the past, most sarcomas were treated with an amputation. Today, approximately 95% of patients can be treated with a limb sparing surgery instead of an amputation. Much of this success is due to advances in surgical technique, development of metallic prostheses to replace bones and joints, better imaging modalities like CT (pronounced CAT) scans and MRIs and improvements in chemotherapy and radiation protocols. Many bony sarcomas (like osteosarcoma) are treated with chemotherapy for a few months to kill the main tumor and any metastases that could have spread throughout the body. Surgery is subsequently performed and the bone or portion of bone containing the tumor (tumor and bone removed together) are removed. Frequently, this requires removal of the adjacent joint. The bony defect is replaced with a metal replacement called a prosthesis. Usually, in approximately 3-4 weeks chemotherapy is resumed. Usually radiation is not administered for bony sarcomas. In many instances, soft tissue sarcomas (sarcomas arising from the muscle or areas between the muscles of the extremities or pelvis) are treated with chemotherapy, followed by surgical resection (limb sparing) and followed with chemotherapy. Radiation may be utilized at some time postoperatively depending upon the size and location of the tumor and the response it had to chemotherapy.

Nowadays, most high grade bone sarcomas (malignancies; cancers) are treated with limb sparing surgery. (Limb sparing surgery refers to surgically removing the tumor without amputating the extremity). The bone that the tumor came from usually requires removal along with the joint that is next to the tumor. Once the tumor, bone and joint are removed, the defect (bone and joint) must be restored with a metallic endoprosthetic replacement or some alternative means of restoring the resected bone. Approximately, 95% of high grade bone sarcomas can be treated with limb sparing surgery. Amputations are rarely performed for primary tumors. If you have a bone sarcoma and you are told that you need an amputation, you should seek an additional opinion. The success of limb sparing surgery can be attributed largely to: the development of effective preoperative and postoperative chemotherapy protocols (kills the tumor and any residual cells which prevents the tumor from coming back after it is removed); advances and increasing experience with complex surgical techniques; the development of durable, mechanically sound and highly functional, metallic endoprosthetic bone and joint replacements; advances in imaging studies such as CT scans and MRIs which allow the surgeon to more accurately plan the surgery.

Almost all benign bone tumors (not cancerous) are treated less aggressively than the malignant bone tumors because they have less chance of coming back after being treated and they do not spread to other body parts. They are rarely ever treated with an amputation. Less complicated surgery is usually performed. Rarely must the bone and joint be resected (removed in entirety). Depending upon the type of tumor, the tumor can usually be curetted (scooped out of the bone). A high speed drill is used to shave the cavity walls until they appear normal. This is referred to as a resectional curettage. Liquid nitrogen (cryosurgery) may be used to freeze the tumor cavity and kill any residual microscopic tumor cells depending upon the type of tumor and its propensity to come back after curetting it; it is tehrefor eused primarily in the treatment of benign agressive tumors. Cryosurgery minimizes the risk of the tumor coming back. After curetting the tumor there is a bony defect (a hole in the bone) that can usually be fixed with methylmethacrylate (bone cement; the hole is filled with bone cement) and bone graft. Metallic rods, plates and screws may utilized to prevent the bone from fracturing (breaking).

Metastatic carcinoma to bone (metastatic cancer) is treated surgically if there is risk that the bone is going to fracture (break); if the bone has already fractured through the tumor; if there is a large soft tissue component ready to invade adjacent nerves, blood vessels, the chest or other critical structures; if the bone tumor represents the only site of metastatic disease (isolated site of metastatic disease). In instances where the tumor represents the only site of disease, the tumor may be treated surgically to remove all gross disease which may cure the patient or may make chemotherapy or immunotherapy protocols more effective. Radiation or other more conservative measures are often utilized if the patient does not meet these criteria or if the patient is too ill to undergo surgery. Surgery for metastatic carcinomas usually consists of stabilizing the bone with a rod and cement or with a long stem joint replacement. Occasionally the tumor will be removed with the bone and joint and the bone and joint will require a metallic endoprosthetic replacement with cement. In general, the operation that is chosen is the procedure that is most reliable with least chance of complications or faiure. It should be the procedure that will relieve the patient's pain and restore function most rapidly and reliably. Radiation may be prescribed postoperatively.

Several different surgical methods are used to treat bone tumors. The type of method that is chosen depends on the type of tumor; the grade of the tumor; the size of the tumor and the tumors inherent ability to come back after it is removed. The types of surgical procedures can be divided into several broad categories. A curettage refers to scooping the tumor out of the bone. This leaves a cavity in the bone (much like a cavity of a tooth). The sides of the cavity are scraped with hand curettes (instruments that look like small deep spoons with sharp edges) and typically shaved with a high speed drill (like a dental drill). The high speed drill removes additional microscopic tumor cells. A curettage is typically performed for benign tumors and metastatic tumors (carcinomas). Cryosurgery refers to freezing the tumor cavity to subzero temperatures with liquid nitrogen in order to kill residual microscopic tumor cells after the curettage and burr drilling. A curettage, alone, may be performed for benign tumors that have small to no risk of returning after the curettage. Curettage and Cryosurgery is performed for benign aggressive tumors (ie. Giant cell tumor); tumors that have a significant risk of coming back after a curettage alone. If these tumors come back they cause more bony destruction and become more difficult to cure. Once the tumor is removed, a hole in the bone exists that must be restored to prevent the bone from breaking and to allow function to return. The hole is usually filled with cement or a combination of cement and bone graft (bone from the patients own pelvic bone). Metal rods, screws and plates may be placed to give additional support to prevent a fracture after surgery. Stabilization procedures are usually performed for metastatic carcinomas. The tumor is usually curetted and packed with cement. Cryosurgery may be used and the bone is stabilized with a metal rod, screws or plates to fix or prevent any fractures from occurring, facilitate nursing care, restore function and relieve pain. Radiation may be prescribed postoperatively.

A limb sparing surgery is also called a resection. Resections are usually performed for malignant tumors and very large benign agressive tumors that have destroyed almost the entire bone. A radical resection is typically performed for high grade tumors. Limb sparing surgery can be performed for approximately 95% of malignant bone tumors. With a resection, the tumor is removed with the bone (or part of the bone) and usually the adjacent joint. The bone and joint must be restored. This part of the procedure is called a reconstruction. Usually a metal prosthesis (replica of the bone and joint) is used to restore (reconstruct) the bony and joint deficiency. Metal prostheses restore the patient to good function rapidly and are associated with few short term complications (ie. Infections) so that chemotherapy can be resumed promptly after surgery (few complications to delay chemotherapy if the type of tumor being treated requires chemotherapy). Ninety to 99% of prostheses last 10 years depending upon the anatomic site in which they are placed.An amputation refers to removal of the entire extremity without replacing it. There are several different types of amputations. The name given to the type of amputation depends upon how much of the limb is removed.

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