What is limb-sparing surgery?
Limb-sparing surgery, also called limb salvage, is a treatment for malignant bone tumors and soft tissue tumors (sarcomas).
Unlike many types of surgery for malignant bone and soft tissue tumors, limb-sparing surgery gives your child a chance to keep the limb (arm or leg) that has the tumor. The techniques used for limb-sparing surgery can also be used for tumors in the pelvis (large hip bone).
Because malignant bone and soft tissue tumors can spread cancer cells to the rest of the body, doctors treat the tumors by removing them. In the past, this usually meant removing (amputating) the child’s limb, often a leg, along with the tumor. Now, most children do not need amputation to control their malignant tumor.
Limb-sparing surgery saves your child’s limb by removing only the tumor and surrounding bone, cartilage or other nearby tissue, not the whole limb.
Once we remove the tumor and surrounding tissue, we use either a bone transplant, called an allograft bone graft, or a metal implant, such as an artificial knee joint, in place of the bone we remove.
When young children are still growing, it is important for surgeons to plan carefully for the child’s growth after surgery. When possible, we try to preserve the growth plate so the bone can keep growing. We can sometimes use a new device called a growing prosthesis that expands while inside your child to match your child’s growth. For some children, we use surgical techniques to decrease the rate of growth at remaining growth plates to keep their legs at even lengths.
Limb-sparing surgery with a bone graft.
Before surgery, an X-ray, an MRI and a PET scan show osteosarcoma in the lower thighbone (red circles in images to the left). Surgeons removed cancerous bone from the middle of the thigh to just above the knee and replaced it with a bone graft. After surgery, an X-ray shows how the graft is held to the patient’s own bone, above and below, by metal pins (image at far right).
Limb-sparing surgery with a metal implant.
Before surgery, an X-ray and an MRI show osteosarcoma in the upper shinbone (red circles in first two images to the left). Surgeons removed the upper shinbone and put in a metal knee replacement (image at far right).
How do you decide if my child can have limb-sparing surgery?
To gather information about your child’s condition and see if your child might be able to have limb-sparing surgery, we look at many images of their bone or soft tissue that has the tumor. We ask your child to have imaging studies before and after chemotherapy and before we take the tumor out.
Doctors at Seattle Children’s were pioneers in the use of the positron emission tomography (PET) scan and the MRI (magnetic resonance imaging) to see if chemotherapy has shrunk a patient’s tumors before surgery.
An MRI is very helpful for deciding how much bone and tissue we should remove along with the tumor during surgery. Imaging studies also help us assess bone healing after a bone graft and implant procedures.
Who gets limb-sparing surgery?
Children and teenagers with osteosarcoma, Ewing sarcoma and other sarcomas can benefit from limb-sparing surgery. Whether your child is a candidate for the surgery depends on several factors, including these:
- The size of the tumor
- Its location
- How much it has spread
Limb-sparing surgery may not be an option if the tumor is too close to a major nerve or artery. Also, before surgery your child must respond well to chemotherapy that shrinks the tumor.
Finally, your child must have enough soft tissue and skin to allow the wound to heal after surgery.
Growing prostheses for young children
Children younger than age 12 who have a tumor in their leg face another challenge. Because they are still growing, we must do surgery to lengthen their affected leg as they get older so it matches the length of their healthy leg.
At Seattle Children’s, we are using new devices called growing prostheses. Growing prostheses are metal implants that can be made longer over time to keep up with your child’s growth.
These devices can make it possible for young children to have limb-sparing surgery even if we must remove a tumor in or near the growth plate in their leg bones.
Surgeons remove your child’s tumor and place the growing prosthesis in your child’s leg during the same surgery. The prosthesis takes the place of the bone that is removed. It is attached to your child’s remaining bone above and below.
As your child gets older, they may still need surgeries to lengthen the affected leg, but a growing prosthesis helps maintain more length in a limb.
We often use this technique in children younger than age 12 — the patients who need the most limb lengthening.
What is your experience with limb-sparing surgery?
Our Pediatric Bone Tumor and Sarcoma Program was the first interdisciplinary program in the nation, and our dedicated team has focused on bone tumors in children, teens and young adults for more than 20 years.
Seattle Children’s has several surgeons who perform limb-sparing surgery. All are trained in both pediatric orthopedic surgery and musculoskeletal oncologic surgery — Drs. Suzanne M. Yandow, Ernest “Chappie” U. Conrad and Antoinette W. Lindberg. Only about a dozen surgeons in the country have this dual training.
We have performed more than 400 limb-sparing procedures for young patients who come from throughout the United States.
What is involved in limb-sparing surgery?
Your child will first have a biopsy by their sarcoma surgeon to confirm they are a good candidate for limb-sparing surgery.
Your sarcoma surgeon should be the one to biopsy your child’s tumor in order to:
- Increase the chance of an accurate biopsy
- Decrease the chance of making later tumor surgery more difficult
For your child to have limb-sparing surgery, the surgeon must be able to leave the nerves, muscles and tendons around the area while taking out enough tissue to control the tumor. Our surgeons use imaging studies before and after your child’s biopsy to make decisions about the details of your child’s full tumor surgery.
Before surgery to remove your child’s tumor, your child may have chemotherapy to shrink the tumor.
During surgery, your child’s doctor will remove the affected part of the bone and replace it with an implant — either a bone transplant (bone graft) or a metal prosthesis, such as an artificial joint.
In some cases, children need several procedures to lengthen their implants to keep up with normal growth or to replace a bone graft, metal plate or other implant.
Read about other aspects of bone tumor and soft tissue tumor treatment.