Amputation for Extremity Sarcoma: Indications and Outcomes

Background: Sarcomas are rare, malignant tumors of soft tissues or bone. Limb salvage surgery (LSS) is the standard treatment, but amputation is still an option, especially in local recurrence or complications after LSS. Methods: We retrospectively reviewed indications and oncological outcomes in patients who underwent an amputation. Two groups with either primary amputations (n = 120) or with secondary amputations after failed LSS with local recurrence or complications (n = 29) were compared with the main end points of LRFS and OS. Results: Five-year LRFS was 84% with 17 (16%) patients developing local recurrence, of which 16 (13%) occurred in group I. Forty-two (28%) patients developed metastatic disease and overall survival at five years was 44%. Overall survival (OS) was the same in both groups. In those group II patients who had a secondary amputation due to LR or insufficient margins after LSS (n = 12) the five-year OS was 33% compared to 48% in patients with amputation due to complications (n = 17) (n.s.). Conclusion: This study indicates the worse oncological outcomes with respect to OS of sarcoma patients requiring an amputation as compared to LSS. Patients with primary amputation or those who had a secondary amputation after failed LSS for whatever reason showed the same oncological results.

Risk Factors for Lower Extremity Amputation Following Attempted Free Flap Limb Salvage

Background Traumatic limb salvage with free flap reconstruction versus primary amputation for lower extremity (LE) injuries remains an oft debated topic. Limb salvage has well-studied benefits and advances in microsurgery have helped reduce the complication rates. A subset of patients eventually requires secondary amputation after a failed attempt at limb salvage. A better understanding of risk factors that predict subsequent amputation after failed free flap reconstruction of LE injuries may improve operative management. Patients and Methods A retrospective study (2002–2019) was conducted on all patients who underwent free flap reconstruction of the LE within 120 days of the original inciting event at a single institution. Patient and operative factors were reviewed including comorbidities, severity of the injury, flap choice, outcomes, and complications. Predictors of subsequent amputation were analyzed. Results A total of 129 patients requiring free flap reconstructions for LE limb salvage met inclusion criteria. Anterolateral thigh flaps (70.5%) were performed most frequently. Secondary amputation occurred in 10 (7.8%) patients. Preoperative factors associated with eventual amputation include diabetes mellitus (p = 0.044), number of preoperative debridements (p = 0.013), evidence of any arterial injury/pathology (p = 0.008), specifically posterior tibial artery (p = < 0.0001), and degree of three-vessel runoff (p = 0.007). Operative factors associated with subsequent amputation include evidence of recipient artery injury/pathology (p = 0.008). Postoperative factors associated with secondary amputation include total flap failure (p = 0.001), partial flap failure (p = 0.002), minor complications (p = 0.037), and residual osteomyelitis (p = 0.028). Conclusion Many factors contribute to the reconstructive surgical team's decision to proceed with limb salvage or perform primary amputation. Several variables are associated with failed limb salvage resulting in secondary amputation. Further studies are required to better guide management during the limb salvage process.

Outcome After Surgical Treatment of Calcaneal Osteomyelitis

Background: Surgical procedures for calcaneal osteomyelitis are partial calcanectomy (PC), total calcanectomy (TC), and below-knee amputation (BKA). With calcaneal osteomyelitis, limb-saving surgery was described to have secondary BKA rates of 4% to 20%, while secondary amputation rates after BKA are unknown. The aim of this study was to describe and compare overall revision and secondary amputation rates for each surgical option in our institution’s cohort and to identify risk factors for secondary amputation. Methods: Fifty patients treated between 2002 and 2017 were included. Revisions, secondary amputations, and possible risk factors for secondary amputation and overall revision were statistically analyzed. Results: Minor revisions rates were 57.1% in PCs, 100% in TCs, and 27.8% in BKAs. Secondary amputation was performed in 28.6% of the PCs, in 50% of the TCs, and in 5.6% of the BKAs. No statistically significant differences between overall revision and secondary amputation rates were found. C-reactive protein values greater than 5 mg/L at the index procedure were significantly associated with overall revision while we could not identify risk factors for secondary amputation. Conclusion: This study represents the largest group of patients treated for calcaneal osteomyelitis in the literature. In limb-preserving surgical options, secondary BKA rates are higher than previously known. Primary BKA is a procedure with a low reamputation rate of 5.6%. PC can be considered, with 28.6% needing more proximal amputation. In TC, all patients underwent revision surgery and 50% had to undergo secondary BKA. Therefore, we hesitate to consider total calcanectomy as a surgical option in calcaneal osteomyelitis anymore. Level of Evidence: Level IV, case series.