Special problems in limb-salvage surgery

Limb-salvage surgery is a safe and effective treatment for malignancies of the musculoskeletal system. Careful evaluation and planning are necessary to avoid both early and late complications. Biopsy must be carefully performed to avoid unnecessary contamination and to obtain adequate tissue for an accurate diagnosis. Pathologic fractures present both a diagnostic and a therapeutic challenge, and evaluation strategies depend on the age of the patient. Treatment of a pathologic fracture depends on the location and the histology of the lesion and many host factors. Limb salvage may or may not be indicated. Instability is another problem with certain limb-salvage situations, e.g., when it is necessary to resect the scapula. Various approaches may obviate the problem. The salvage of failed limb-salvage procedures requires careful evaluation and planning. Patients with infections and local recurrences often require amputation surgery. Correctable problems following failed allograft reconstructions include collapse of the articular cartilage, joint instability, nonunion, and fracture of the allograft. Correctable problems following prosthetic arthroplasty include aseptic loosening, prosthetic fracture, and polyethylene wear. Approximately two thirds of patients with failed limb-salvage procedures will obtain a functional limb following revision surgery. Attention to these special problems may allow for greater success with limb-salvage surgery.