Limb-Sparing Surgery (Limb-Salvage)

Limb-sparing surgery, or limb salvage, is an operation used to treat bone or soft tissue cancer in an arm or leg. The goal is to remove the tumor while saving as much of the limb as possible. 

Surgeons remove the tumor and some of the surrounding tissue to make sure all the cancer is gone. Then they rebuild the limb using a metal rod (prosthesis) or a piece of bone (graft). 

Limb-sparing is a major surgery. Only a surgeon with special training and experience should perform it. 

Your child’s arm or leg will be different from what it was before surgery, and they will need rehabilitation therapy to learn how to use the limb again. Your care team will work with you to create a treatment and recovery plan for your child. 

Benefits of limb-sparing surgery

Limb-sparing surgery removes the tumor and nearby tissue and may be an option instead of having an amputation (removal of the limb). Potential benefits include:

• Removal of cancerous and damaged tissue while preserving the limb
• Improved movement and function of the limb
• Better quality of life and greater independence
• More natural appearance of the limb

Before limb-sparing surgery

Many things happen before limb-sparing surgery. 

Limb-sparing surgery is used in combination with other treatments to treat cancers such as osteosarcoma, Ewing sarcoma, and soft tissue sarcoma. 

Your child may have chemotherapy to shrink the tumor before surgery. Some patients may also have radiation therapy. Treatments will depend on your child’s specific diagnosis.   

Your care team will do tests, such as biopsy and imaging tests, to learn as much as they can about the tumor and its location. 

Biopsy

A biopsy is a procedure to remove a small tumor sample. A pathologist looks at it under a microscope to identify the type and grade of tumor. The grade tells how likely it is that the cancer will spread. A low-grade tumor has a low chance of spreading. A high-grade tumor has a high chance of spreading.

Imaging tests

Imaging tests, such as magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography (PET), or PET-CT, help your care team know:

• The size and location of the tumor
• If the tumor has grown into nearby nerves, blood vessels, tendons, and other tissues
• If the surgery involves an area of new bone growth (growth plate)
• The stage of cancer (whether the tumor is in one place or if it has spread to other parts of the body)

Meeting with your care team

You will meet with several care team members before surgery, including:

• Surgical team: They will explain the surgery and recovery process.
• Anesthesiology team: They will talk to you about anesthesia and pain medicine.
• Rehabilitation team: They will discuss plans for physical therapy or occupational therapy after surgery.

Other specialists may include psychologists, child life specialists, dietitians, and other members of the care team. Be sure to ask your care team any questions you have. If you do not understand something, ask them to explain it again.  

What happens the during limb-sparing surgery

The limb-sparing procedure will take most of the day. The day of the surgery includes:

1. Pre-surgery preparation
2. Removal of the tumor
3. Reconstruction of the affected arm or leg
4. Post-surgery recovery

Limb-sparing surgery is a complex operation. First, surgeons remove the entire tumor and surrounding tissue. They must take extreme care because the procedure affects bone, tissue, blood vessels, and nerves. 

Then, surgeons reconstruct the arm or leg. They replace the bone with a metal internal prosthesis or a bone graft. 

If your child is still growing, they may get a prosthesis that can expand as they grow. If they have finished growing, they will get an adult prosthesis. 

Your child may need a skin graft to cover the wound and help with healing. In a skin graft, the skin comes from another area of your child’s body.

What to expect when your child wakes up after surgery

Your child will have several medical devices to help with healing and recovery. These may include: 

• Catheter and pump for pain control: Your child may have a catheter, or small tube, that is connected to a pump that gives pain medicine. This may include a nerve block or epidural anesthesia. The type and location of the catheter will depend on what part of the body is affected. Catheters may stay in for a few days. 
• Splint or brace: Your child may have a splint or brace on the limb to keep it stable. This protects the limb and gives the implant or bone graft time to heal.  
• Drains: Your child may have a drain or tube in the wound where the surgeon made incisions (cuts). The drain takes away excess fluid and blood. 
• Dressings: Your child will have wound dressings to cover areas where the surgeon made incisions or where you had skin grafts. The dressing protects these areas from infection and injury.  
• Wound vac: Your child may have a wound vac machine to help with wound healing. This is also called negative pressure wound therapy. It holds the incision together, gets rid of any remaining fluid, improves blood flow, and reduces swelling. 

What to expect after limb-sparing surgery

Pain management

Pain is the most common side effect after limb-sparing. Your care team will help you manage pain with medicine and other methods. The goals are to reduce pain after surgery and to prevent chronic pain in the future.  

Opioids: Doctors may prescribe opioids such as morphine for pain after surgery. These medicines are effective for short-term pain relief. But they also have side effects. To decrease the risk of side effects, your care team may use other pain relief medicines and non-medicine approaches.

Medicines for nerve pain: Your child may get medicines for nerve (neuropathic) pain, such as gabapentin or pregabalin. Your child may get this medicine before and after surgery. Patients describe nerve pain as burning, shooting, tingling, or “pins and needles.” If your child has this type of pain, they may continue the medicine for 1–3 months after surgery to allow nerves to heal. Over time, the care team will lower the amount of medication. 

Other pain medicines include acetaminophen (Tylenol®) and non-steroidal anti-inflammatory medications (NSAIDs). 

Regional pain relief: Regional pain relief includes nerve blocks and epidural anesthesia. Your care team injects pain medicine through a catheter to provide pain relief in a specific area of the body. This can help to relieve pain after surgery and prevent chronic pain. 

Other pain management options

You can also manage pain without medicine. Options may include strategies such as: 

• Cold therapy or heat therapy as instructed by your care team
• Relaxation techniques such as guided imagery and deep breathing 
• Distraction  
• Mindfulness 
• Having good sleep habits
• Cognitive behavioral therapy to change thinking patterns and behavior to cope with pain  

It is important to set realistic expectations of pain. Your child will likely have some pain. But the care team’s goal is to keep pain at a manageable level. 

Wound care

Wound care is important to promote healing and help prevent infections. Your care team will give instructions for wound care, including dressing changes. Your child will get antibiotics to help prevent infection. The care team will watch for signs of infection, blood clots, and other possible complications.

Treatments such as chemotherapy may cause slow wound healing. But it is important to stay on track with your child’s cancer treatment. 

Rehabilitation therapy

Rehabilitation therapy is the key to regaining as much function as possible after limb-sparing surgery. Your child will begin therapy soon after surgery while they are still in the hospital. 

Therapists will work with your child to build muscle strength and endurance. They will also help your child learn how to do daily activities and use assistive devices as needed. Your child will continue rehabilitation sessions in your home community after you leave the hospital. Your care team can help connect you with local services and providers. 

Therapy sessions may be tiring and painful, but it is important that your child attends and works hard in each session. Over time, your child will feel stronger and have better movement and function.

Therapists will also give your child exercises to do at home. Following the therapy plan helps to reduce the risk of injury, manage pain, and improve function.

To have the best possible recovery, it is important to:

• Attend all scheduled therapy sessions
• Work as hard as possible
• Do home exercises as instructed

Follow-up appointments

Your child will have follow-up appointments with their surgeon. Appointments will be every 1-2 weeks at first and then occur less often. After 5 years, follow-ups are usually once a year. 

Prosthesis adjustments 

If your child has an expandable prosthesis, they will have small adjustments as they grow. The adjustments are usually done during an outpatient visit. A magnetized device is used to lengthen the limb without surgery. 

It is important to get adjustments on schedule to make sure that the leg that had surgery stays the same length as the other leg.  

Physical activity precautions

After surgery, your care team will let you know what activities your child can and cannot do. These are called precautions. It is important to follow your care team’s instructions to give the body time to heal. Most precautions will change over time. 

Your child’s ability to do some physical activities may be different than before surgery. In some cases, your child may need to stop doing certain activities, such as contact sports. 

Coping with changes

Limb-sparing surgery often means your child can keep more natural movement and independence, which can make daily life easier. But your child may have different feelings about how their body looks or moves after surgery. This is completely normal. They might feel sad, angry, or frustrated, especially if they give up a sport or activity they enjoyed.

Here are some ways to help your child cope:

• Encourage your child to talk about their feelings — it’s okay to be upset, worried, or even angry.
• It can sometimes help to connect with other kids who have had similar surgery to help them feel less alone.
• Celebrate small wins, like getting stronger, moving more easily, or returning to school.
• Focus on what your child can do, not just what they can’t or what has changed. They may find new hobbies or activities they enjoy. Over time, your child may even return to sports or activities they love, sometimes in new ways. 

Your care team, including psychologists, social workers, and child life specialists, can help your child cope and adjust.

Possible risks of limb-sparing surgery

Possible risks of limb-sparing surgery include:

• Infections  
• Problems with the prosthesis or bone graft  
• Blood clots
• Limb stiffness
• Differences in limb length
• Return of cancer

Your child will need to take antibiotics before any dental work, procedure, or surgery to help prevent infection.

Talk to your care team about questions or concerns you have about your child’s surgery.

When to call your care team

Seek medical care if your child:

• Has a fever or has warmth, swelling, redness, or discharge around the wound
• Injures the limb that had surgery
• Has more pain than usual, or pain is hard to manage
• Has trouble moving, bending, or using the limb

Questions to ask your care team

• Is limb-sparing surgery an option for my child?
• What are the benefits and risks of limb-sparing surgery?
• What are other treatment options?
• How long will my child stay in the hospital after limb-sparing surgery?
• What does recovery from limb-sparing surgery look like?
• What activities should my child avoid after surgery?
• What is the care team’s experience with this surgery?