According to a review, limb-sparing surgery may not provide additional benefit for bone and soft tissue sarcoma patients. The review, Bone and Soft Tissue Sarcomas Are Often Curable – But At What Cost? A Call to Arms and Legs, by Ronald D. Barr, MD of McMaster University and Jay S. Wunder, MD of the Mount Sinai Hospital and University of Toronto, calls into question the belief that limb-sparing surgery is the preferred method of care and will lead to a better heath-related quality of life among sarcoma patients.
“There is a general assumption of greater benefit from limb salvage than amputation, but many amputees do well and some patients who have undergone limb salvage do not,” Barr said to O&P Business News.
Barr and Wunder reviewed all published papers on limb-sparing surgery in order to compare the costs and benefits of amputations compared with limb-sparing surgery in sarcoma patients. According to the review, bone and soft tissue sarcomas are relatively common in the adolescent and young adult age group accounting for 6% to 7% of incident cases of cancer in patients 15 to 29 years old. However, that number only represents a small fraction of the total cancer burden. In fact, the small number of cases for this type of assessment was one of the challenges that faced the authors. Despite the challenges, some clear messages were noted in the review.
According to the review, studies show that in patients with lower limb bone sarcomas, limb salvage does not provide a better quality of life than amputations. This is important because in recent years there has been improved survival in patients with bone and soft tissue sarcomas and focus on a patient’s quality of life has increased.
Studies also indicated that the differences in disability between amputation and limb salvage patients were smaller than anticipated. According to the review, studies revealed no significant differences in psychological outcomes between amputees and those who have undergone limb salvage.
The review acknowledges that while there is general agreement that limb-sparing surgery is the preferred approach for patients with upper extremity tumors, the evidence for the lower extremity is less clear. According to the review, there does appear to be a greater advantage in limb sparing surgery than amputation for higher surgical sites in the lower limb, such as the hip. Studies in the review did show that functional outcomes were better after limb-sparing surgery than transfemoral amputation or hip disarticulation as well.
A review of studies that compared the costs of amputation and limb-sparing surgery found that while the up front costs of surgery, rehabilitation duration and need for revisions are all greater for limb-sparing procedures, amputation carries longer term costs. These costs are related to artificial limb manufacturing, maintenance and replacement.
“Although it appears that the number of amputations per year has decreased with time, it cannot be assumed that limb-salvage surgery will offer a better functional outcome and health-related quality of life for young people with bone and soft tissue sarcomas,” the authors wrote. — Anthony Calabro
In my opinion, limb salvage is acceptable in the high femur and in the hip area, however not for the distal femur or tibial-type tumors. There are just too many better options that produce better outcomes, such as the rotationplasty the tibial turn-up and below and above knee amputation. Kids with limb-salvage are more prone to re-injury. This is certainly the case if they are trying to get back into contact sports or high-impact activities.
The cost of the prosthetics is definitely higher. But what I have seen are repetitive surgeries for limb salvage, especially kids who are too active. Kids, who have decided to go with an amputation, have no limitations in their activities. To me, that brings out a more normal lifestyle for younger children.
—Stephen Miller, CPO
Area Practice Manager, Hanger Prosthetics and Orthotics