Limb Salvage vs Amputation

Limb Salvage and Amputation 

Orthopedic oncology is a multidisciplinary specialty concerned with the diagnosis and management of bone and soft tissue tumors. A pivotal decision in this field is whether the affected limb can be preserved or requires amputation. Historically, amputation was the standard treatment for malignant bone tumors. However, advances in imaging modalities, chemotherapy, radiotherapy, and surgical techniques have allowed limb salvage surgery to become a safe and effective alternative in many cases. The primary objective is to achieve oncologically safe resection margins while preserving limb function and appearance.

Development and Indications of Limb Salvage Surgery

Limb salvage surgery involves complete tumor excision with negative margins, followed by reconstruction of the resulting defect. The success of this procedure depends on tumor location, proximity to neurovascular structures, and patient-specific factors such as overall health and rehabilitation potential.

 

Absolute Indications:

• Tumor can be resected with safe margins without compromising major vessels or nerves.
• Tumor reduction after neoadjuvant chemotherapy allows safe surgical margins.
• Localized disease with no distant metastasis.

 

Relative Indications:

• Limited soft tissue involvement.
• Absence of active infection or impaired wound healing.
• Patient’s physical and psychological capacity for rehabilitation.

Reconstruction techniques include modular tumor prostheses, autografts or allografts, rotationplasty, and vascularized fibular grafts. These strategies aim to restore limb length and maximize post-operative function.

Indications and Role of Amputation

Despite the advantages of limb salvage, amputation remains necessary in selected patients to ensure oncologic safety and optimal quality of life. Absolute indications include encasement of major neurovascular structures, uncontrolled infection, extensive soft tissue necrosis, or inability to achieve negative margins.

Absolute Indications:

• Tumor involving major arteries or nerves.
• Widespread infection or chronic osteomyelitis.
• Recurrent tumors where reconstruction is not feasible.
• Inability to achieve oncologically safe margins.

 
Relative Indications:

• Patients with comorbidities precluding long or complex surgery.
• Technical limitations preventing reconstruction.
• Patient preference or anticipated noncompliance with rehabilitation.

Modern prosthetic technology has significantly improved post-amputation functional outcomes and mobility.

Oncologic and Functional Outcome Comparison

Several studies have demonstrated no significant difference in long-term survival between limb salvage and amputation, provided negative surgical margins are achieved. Local recurrence risk remains primarily dependent on margin status. Functionally, limb salvage generally yields superior outcomes. Functional scores such as the Musculoskeletal Tumor Society (MSTS) score and Toronto Extremity Salvage Score (TESS) are typically higher in limb salvage patients (%70–80) compared to amputees (%50–60). However, limb salvage procedures are associated with higher rates of early complications including infection, prosthesis loosening, and mechanical failures. Amputation, conversely, presents fewer surgical complications but poses greater psychosocial adaptation challenges.

Complications and Rehabilitation

The most common complications after limb salvage surgery include wound healing problems, deep infections, implant loosening, and fractures. In pediatric patients, expandable prostheses are often employed to accommodate ongoing growth. After amputation, patients frequently encounter phantom limb pain, skin irritation, and challenges with prosthesis fitting. Rehabilitation requires a multidisciplinary approach involving physiotherapy, psychological support, and prosthetic training to optimize functional independence.

Conclusion and Future Perspectives

Limb salvage surgery in orthopedic oncology offers superior functional and aesthetic outcomes in appropriately selected patients. Individual patient assessment remains critical. Future advances, including 3D printing, biologic reconstruction, and improved understanding of chemoresistance mechanisms, are expected to enhance limb salvage success. Nonetheless, the fundamental principle remains unchanged: oncologic safety must always take precedence over functional preservation.

References:

1. Simon MA, Aschliman MA, Thomas N, Mankin HJ. Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg Am. 1986;68(9):1331–1337.

2. Gonzalez, M. R., Mendez-Guerra, C., Goh, M. H., & Pretell-Mazzini, J. (2025). Principles of Surgical Treatment of Soft Tissue Sarcomas. Cancers, 17(3), 401.

3. Grimer, R. J., Taminiau, A. M., & Cannon, S. R. (2002). Surgical outcomes in osteosarcoma. The Journal of Bone & Joint Surgery British Volume, 84(3), 395-400.

4. Aksnes LH, Bauer HC, Jebsen NL, et al. Limb-sparing surgery preserves more function than amputation: a Scandinavian Sarcoma Group study of 118 patients. J Bone Joint Surg Br. 2008;90(6):786–794.

5. Chandrasekar CR, Grimer RJ, Carter SR, et al. Modular endoprosthetic replacement for tumours of the proximal femur. J Bone Joint Surg Br. 2009;91(1):108–112.

6. Malawer, M. M., & Sugarbaker, P. H. (Eds.). (2006). Musculoskeletal cancer surgery: treatment of sarcomas and allied diseases. Springer Science & Business Media.

7. Davis AM, Bell RS, Badley EM, et al. Evaluating functional outcome in patients with lower extremity sarcoma. Clin Orthop Relat Res. 1999;(358):90–100.

8. Cirstoiu, C., Cretu, B., Serban, B., Panti, Z., & Nica, M. (2019). Current review of surgical management options for extremity bone sarcomas. EFORT open reviews, 4(5), 174-182.