Indications of amputation after limb-salvage surgery of patients with extremity-located bone and soft-tissue sarcomas: A retrospective clinical study (2024)

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  • Acta Orthop Traumatol Turc
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Indications of amputation after limb-salvage surgery of patients with extremity-located bone and soft-tissue sarcomas: A retrospective clinical study (1)

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Acta Orthop Traumatol Turc. 2021 Mar; 55(2): 154–158.

PMCID: PMC11229619

PMID: 33847578

Özgür Baysal,Indications of amputation after limb-salvage surgery of patients with extremity-located bone and soft-tissue sarcomas: A retrospective clinical study (2) Fevzi Sağlam, Ömer Sofulu, Okan Yiğit, Evrim Şirin, and Bülent Erol

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Abstract

Objective

This study aimed to investigate amputation-related factors after limb-salvage surgery (LSS) in patients with extremity-located bone and soft-tissue sarcomas and determine the relationship between these factors and patient survival.

Methods

In this retrospective study at our institution, patients in whom LSS was first performed because of an extremity-located musculoskeletal sarcoma, and subsequently amputation was carried out for various indications were included. Patient and tumor characteristics, details of surgical procedures, indications of amputation, number of operations, presence of metastasis before amputation, and post-amputation patient survival rates were analyzed.

Results

A total of 25 patients (10 men, 15 women; mean age=41.96±21.88 years), in whom amputation was performed after LSS as initial resection of an extremity sarcoma or re-resection(s) of a local recurrence, were included in the study. The leading oncological indication for amputation was local recurrence that occurred in 18 (72%) patients. Non-oncological indications included prosthetic infection in 5 (20%), mechanical failure in 1 (4%), and skin necrosis in 1 (4%) patient. The patients underwent a median of 2 (range, 1–4) limb-salvage procedures before amputation. Distant organ metastasis was detected in 22 (88%) patients during follow-up; in 13 (52%) of these patients, metastasis was present before amputation. A total of 11 (44%) patients were alive at the time of study with no evidence of the disease (n=3) or with disease (n=8), and 14 (56%) patients died of disease. The mean overall and post-amputation survival were 47±20.519 (range, 11–204) months and 22±4.303 (range, 2–78) months, respectively. The median follow-up was 27 (range, 6–125) months.

Conclusion

The most common causes of amputation after LSS were local recurrence and prosthetic infection. Patients who underwent amputation after LSS developed a high rate of distant organ metastasis during follow-up and had reduced survival.

Level of Evidence

Level IV, Therapeutic Study

Keywords: Extremity, Sarcoma, Amputation, Limb salvage surgery, Local recurrence

Introduction

Limb-salvage surgery (LSS) preserves a better quality of life and functional capacity than amputation in the treatment of malignant musculoskeletal tumors (1). However, there is no difference between these 2 surgical treatment modalities in terms of survival and relapse of the disease when appropriate surgical margins are obtained (1).

Although amputation has been frequently performed for treatment of malignant bone and soft-tissue tumors in the past, currently LSS has become the standard of care with the advances in chemotherapy regimens, improvements in imaging studies, and accumulation of experience in musculoskeletal reconstructive surgery (13). There are 2 key factors to be considered for LSS: wide surgical margins should be obtained to ensure that the survival of the patient is better than that with amputation, and the reconstructed extremity should function satisfactorily (4, 5). LSS is only occasionally an option for management of recurrent bone and soft-tissue sarcomas because appropriate surgical margins can be usually obtained by an amputation (2, 3).

The factors that can affect extremity survival after LSS have been reported in the literature (68). However, there is limited research investigating the overall and post-amputation survival of these patients. This study mainly aimed to determine the frequency of amputation after LSS of extremity-located bone and soft-tissue sarcomas at a tertiary musculoskeletal oncology center. The effect of tumor- and surgery-related factors on amputation, oncological or non-oncological indications, number and type of surgical interventions before amputation, and association of distant organ metastasis with amputation were also investigated in addition to overall and post-amputation survival.

Materials and Methods

This retrospective study included patients who underwent LSS owing to an extremity-located musculoskeletal sarcoma and required amputation during follow-up for various indications at our institution. Patients, who underwent a primary amputation because of malignant bone and soft-tissue tumors of the extremities, including malignant skin tumors, were excluded. The study protocol was approved by the local ethics committee of Marmara University School of Medicine (09.2020.8).

The demographic characteristics of patients (age and sex), tumor characteristics (diagnosis, localization, depth, size, and histopathological grade), status of the surgical margins (wide, marginal, or intralesional), wound closure method (primary, skin graft, or free flap), indications of amputation (local recurrence, prosthetic infection, mechanical failure, or skin necrosis), number of operations before amputation, presence of metastasis before amputation and during follow-up, survival of patients after initial LSS (overall survival) and amputation (post-amputation survival), and duration of follow-up were accessed from the archived files and digital hospital records. All patients in this study were treated with a multidisciplinary approach according to the decision of the Bone and Soft Tissue Tumors Council of Marmara University Pendik Training and Research Hospital.

Statistical analysis

Data analysis was carried out using the Statistical Package for Social Sciences version 22.0 software (IBM SPSS Corp.; Armonk, NY, USA). The study data were evaluated using descriptive statistical methods (mean, standard deviation, median, frequency, ratio, minimum, and maximum). Survival curves were calculated using the Kaplan-Meier method.

Results

A total of 57 (8.7%) of 654 patients with a diagnosis of extremity-located primary bone or soft-tissue sarcoma underwent amputation at our institution between 2009 and 2018. Of these, 32 (4.9%) patients underwent a primary amputation at first surgery to achieve appropriate surgical margins, and these patients were not included this study. Amputation was performed after LSS in 25 (3.8%) patients, which was done as initial resection of an extremity sarcoma or re-resection(s) of a local recurrence. Of these 25 patients, 12 had their initial LSS at another center and 13 at our institution.

Table 1 summarizes a descriptive analysis of the demographic characteristics of the patients, tumor characteristics, details of surgical procedure, indications for amputation, existence of metastasis before amputation or at follow-up, survival status, and follow-up of the patients. Table 2 gives the localization of the tumors and amputation levels of the extremities in detail.

Table 1

Descriptive analysis of demographic characteristics of the patients and tumor characteristics

n (%)
Age (years)Min-max (median)1–71 (44)
Mean±SD41.96±21.88
SexFemale10 (40.0)
Male15 (60.0)
DiagnosisOsteosarcoma9 (36.0)
Ewing sarcoma3 (9.0)
Pleomorphic sarcoma3 (9.0)
Chondrosarcoma2 (8.0)
Fibrosarcoma2 (8.0)
Dermatofibrosarcoma protuberans1 (4.0)
Leimyosarcoma1 (4.0)
Myofibroblastic sarcoma1 (4.0)
Myxofibrosarcoma1 (4.0)
Rabdomyosarcoma1 (4.0)
Synovial Sarcoma1 (4.0)
Tumor localizationUpper extremity6 (24.0)
Lower extremity19 (76.0)
Tumor depthSuperficial0 (0.0)
Deep25 (100.0)
Tumor size (cm)Min-max (median)4–30 (9)
Mean±SD10.20±5.45
Tumor gradeGrade 14 (16.0)
Grade 23 (12.0)
Grade 318 (72.0)
Surgical marginWide16 (64.0)
Marginal5 (20.0)
Intralesional4 (16.0)
Closure of woundPrimary18 (72.0)
STSG3 (12.0)
Free flap4 (16.0)
Indications of amputationOncological indications
Local recurrence18 (72.0)
Non-oncological indications
Prosthetic infection5 (20.0)
Mechanic failure1 (4.0)
Skin necrosis1 (4.0)
Number of operations before amputationMin-max (median)1–4 (2)
Mean±SD2±0.76
Amputation decision for oncological indications1st local recurrence4 (22.2)
2nd local recurrence11 (61.1)
>2nd local recurrence3 (16.7)
Metastasis before amputationYes13 (52.0)
No12(48.0)
Metastasis at follow-upYes22 (88.0)
No3 (12.0)
Survival statusAlive11 (44.0)
Dead14 (56.0)
Follow-up (month)Min-max (median)6–125 (27)
Mean±SD39.88±31.59

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SD: standard deviation; STSG: split thickness skin graft.

Table 2

Descriptive analysis of tumor localization and amputation level

Tumor localizationn%
Thigh28
Distal femur624
Knee14
Proximal tibia520
Ankle28
Foot312
Shoulder14
Arm416
Forearm14
Amputation leveln%
Hip disarticulation624
High transfemoral28
Above knee520
Below knee520
Ray amputation14
Forequarter520
Transhumeral14

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Local recurrence was the leading oncological indication for amputation and occurred in 18 (72%) patients. Non-oncological indications included prosthetic infection in 5 (20%), mechanical failure in 1 (4%), and skin necrosis in 1 (4%) patient. A total of 4 (22.2%) patients with local recurrence had amputation after first local recurrence. In the remaining 14 (78.8%) patients, amputation was indicated after the second or subsequent local recurrences. Patients experienced a median of 2 (range 1–4) limb-salvage procedures before amputation.

Distant organ, particularly lung, metastases was detected in 22 (88%) patients during follow-up. In 13 (52%) patients, metastatic involvement was already present before amputation (in 5 patients at initial presentation and in 8 patients during the period between initial presentation and amputation). Distant organ metastasis was detected after amputation in the remaining 9 (36%) patients. A total of 11 (44%) patients were alive at the time of the study with no evidence of the disease (n=3) or with disease (n=8), and 14 (56%) patients died of the disease. Of the 14 patients who died, 9 died within a median of 5 (range, 2–8) months after amputation, and only 5 survived for a median of 22 (range, 14–30) months. The mean overall and post-amputation survival durations of the patients were 47±20.519 (range, 11–204) months and 22±4.303 (range, 2–78) months, respectively. The Kaplan-Meier analysis of overall and post-amputation survival demonstrated that patients who underwent amputation after LSS had reduced survival rates (Figure 1). The median duration of follow-up was 27 (range, 6–125) months.

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Figure 1

The Kaplan-Meier analysis of overall and post-amputation survival of patients

Discussion

A search of our database, including the time period of the study, revealed that patients who required secondary amputation (amputation after LSS) constituted 3.8% (25/654) of our extremity-located musculoskeletal sarcoma cohort. The tumors were usually larger than 5 cm, were deeply located, and were of high grade. Local recurrence and prosthetic infections were the leading oncological and non-oncological indications for amputation, respectively. Patients experienced a median of 2 (range, 1–4) limb-salvage procedures before amputation. A high percentage of patients (88%; 22/25) were found to develop distant organ metastases during follow-up. The mean values of overall and post-amputation survival of patients were 47±20.519 and 22±4.303 months, respectively. Patients who underwent amputation after LSS developed a high rate of distant organ metastasis during follow-up and had reduced survival.

Table 3 gives the comparative data of the previous related studies (68) and this study, which evaluated patients with sarcoma requiring amputation after LSS, in terms of the amputation rate, patient and tumor characteristics, surgical margins, rate of metastatic involvement before and after amputation, and indications for amputation. In the literature, the rate of amputation after LSS has been reported between 9% and 14% (6, 9, 10). This rate was 3.8% (25/654) in this study, and only 0.6% (4/654) of patients underwent amputation after the first local recurrence. We put forward 2 main reasons to explain this low rate of secondary amputation in our extremity-located musculoskeletal sarcoma cohort. First, the sociocultural structure of the society in the country in which this study was conducted strictly prevents patients from agreeing to an amputation. Second, the progressively increasing experience and collaboration of our multidisciplinary team, which included experienced cardiovascular and reconstructive surgeons, expanded the range of our indications for LSS, particularly in re-resections of local recurrences and revision of bone reconstructions. It should also be mentioned that all patients in these situations were informed about the consequences of re-resections and revisions and the possibility of a secondary amputation.

Table 3

Comparison of the characteristics of disease and patients undergoing amputation after limb-salvage surgery for extremity sarcomas

Stojadinovic et al., 2001Smith et al., 2017Erstad et al., 2018Present Study
Age (Median)39615244
Amputation after LSS18362225
Amputation decision for first recurrence18 (100.0)21 (58.3)18 (81.8)4 (16.0)
Tumor size
 <5 cm7 (38.9)Nr4 (18.2)2 (8.0)
 5–10 cm5 (27.8)Nr10 (45.5)14 (56.0)
 >10 cm6 (33.3)Nr7 (31.8)9 (36.0)
 Nr0 (0.0)0 (0.0)1 (4.5)0 (0.0)
 MedianNr9.3Nr9
Tumor grade
 Low grade0 (0.0)1 (2.8)1 (4.6)4 (16.0)
 Intermediate grade0 (0.0)15 (41.7)2 (9.1)3 (12.0)
 High grade18 (100.0)19 (52.7)16 (72.7)18 (72.0)
 Nr0 (0.0)1 (2.8)3 (13.6)0 (0.0)
Tumor localization
 Upper extremity10 (55.6)23 (63.9)6 (27.3)6 (24.0)
 Lower extremity7 (38.9)13 (36.1)14 (63.6)19 (76.0)
 Trunk1 (5.5)0 (0.0)2 (9.1)0 (0.0)
Tumor margin
 Negative9 (50.0)Nr10 (45.5)16 (64.0)
 Positive9 (50.0)12 (54.5)9 (36.0)
Tumor depth
 Superficial0 (0.0)Nr5 (22.7)0 (0.0)
 Deep18 (100.0)16 (72.7)25 (100.0)
 Nr0 (0.0)1 (4.6)0 (0.0)
 Metastasis before amputation3 (16.7)Nr4/17 (23.5)13 (52.0)
 Metastasis after amputation13 (72.2)Nr17 (77.3)22 (88.0)
Amputation indication
 Oncological indication18 (100.0)36 (100.0)17 (77.3)18 (72.0)
 Non-oncological indication0 (0.0)0 (0.0)5 (22.7)7 (28.0)
 Post-amputation local recurrence1 (5.5)Nr2/17 (11.8)0 (0.0)

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Nr: not recorded; LSS: limb-salvage surgery.

A comparison of the previous studies in the literature with our study revealed that similar tumor characteristics, including size larger than 5 cm, deep location, and high grade, were associated with extremity sarcomas requiring amputation after LSS (68). Malignant bone and soft-tissue tumors with these features had a worse prognosis than that of small-sized, superficial, and low-grade sarcomas (11). We speculate that after LSS of an extremity sarcoma with aggressive radiological and histopathological features, short- or long-term complications, including local recurrence, are more likely.

A study by Stojadinovic et al. and Smith et al. has reported that a large number of tumors located in the upper extremities required amputation after LSS (6, 8). These tumors could invade or expand very close to major neurovascular structures; therefore, surgical margins frequently may remain marginal or intralesional, leading to local recurrence and subsequent re-resection or amputation (2). However, non-oncological causes of amputation, mainly prosthetic infections or mechanical failures, were seen very rarely after upper extremity reconstructions.

Bone and soft-tissue sarcomas occur more commonly in the lower extremities (12). Besides oncological indications, non-oncological complications, including prosthetic infection, mechanical failure of an endoprosthesis, or insufficient soft-tissue coverage may result in amputation after LSS. Erstad et al. have reported a higher number of amputations after LSS of lower extremity sarcomas (7). In this study, 76% (16/25) of the tumors requiring amputation after LSS were located in the lower extremities. The leading oncological indication for amputation was local recurrence that occurred in 18 (72%) patients. Non-oncological indications included prosthetic infection in 5 (20%), mechanical failure in 1 (4%), and skin necrosis resulting in insufficient soft-tissue coverage for bone reconstruction in 1 (4%) patient.

A high rate of tumor-positive surgical margins, ranging from 50% to 54.5%, has been reported in patients who require amputation because of local recurrence after LSS (6, 7). The rate of tumor-positive surgical margins was also high in this study; 36% (9/25) of patients with marginal or intralesional surgical margins had a local recurrence and subsequently underwent amputation during follow-up, demonstrating the negative effect of inappropriate resections on extremity survival.

The main complications after LSS include instability, soft-tissue insufficiency, mechanical failure, infection, local recurrence, and non-union or graft resorption for biological reconstructions (1, 4, 13). Local recurrence and infection were found to be the 2 most common causes of amputation (4). In this study, the most common indication leading to amputation after LSS was local recurrence followed by prosthetic infection, and these findings were consistent with the literature.

Bone defects occurring after resection of malignant bone and soft-tissue tumors in the lower extremities are often reconstructed with a mega-prosthesis (2, 3). Prosthetic joint infections (PJI) are divided into 3 groups; early onset (<3 months), delayed onset (>3 months, <12 months), and late onset (>12 months) (14). In our study, 20% (5/25) of patients required amputation after LSS because of a delayed-onset (3/25) or late-onset (2/25) infection of a mega-prosthesis. A two-staged revision is the most preferred surgical treatment for late infections of mega-prostheses (15). We followed a similar approach and performed a two-stage revision in the management of 5 patients with delayed or late-onset PJI. Soft-tissue reconstruction was provided by local pediculated or free flaps when required. However, eventually an amputation was required because of recurrent infections and insufficient soft-tissue coverage.

The rate of distant organ metastasis before amputation has been reported between 16.7% and 23.5% in patients with previous LSS (6, 7). In addition, considerably increased metastases rates have been reported at follow-up, particularly in patients with local recurrence (16, 17). In this study, the rate of distant organ metastasis before amputation and during follow-up was 52% (13/25) and 88% (22/25), respectively. We believe that this high rate of distant metastasis was related to the high percentage (72%; 18/25) of local recurrences in our patient cohort, which required amputation after LSS. We can also argue subjectively that our low rate of amputation after the first local recurrence may have increased the development of distant metastasis.

Amputations performed on patients with sarcoma with distant organ metastasis are known as palliative amputations in the literature (8). Smith et al. have reported a mean survival of 6 months in patients undergoing palliative amputation (8). The study by Stajodinovic et al. has reported a median survival of 19.6 months and a low rate of distant organ metastasis before the first recurrence (6). In this study, the rate of palliative amputation was 52% (13/25). We believe that distant organ metastasis is a significant parameter affecting patient survival.

The rates of local recurrence after amputation have been reported to be between 5.5% and 11.8% (6, 7) with no local recurrence observed after amputation in this study. Achieving appropriate surgical margins with amputation could be an important factor. In addition, as most of the patients had metastatic disease, follow-up after amputation was short for development of a recurrence.

This study had some limitations. First, it was a retrospective study with a small number of patients treated in a single center. Second, there was no control group. Third, a subgroup analysis was not possible owing to the heterogeneous diagnoses and localization of the tumors. However, it is one of the rare studies scrutinizing the etiological factors and the effect of amputation on survival in patients requiring amputation after LSS of extremity-located malignant bone and soft-tissue tumors.

In conclusion, the initial management and follow-up of extremity-located musculoskeletal sarcomas require a multidisciplinary approach. In our study, the most common oncological and non-oncological causes of amputation after LSS were local recurrence and prosthetic infection, respectively. The large, deeply located, and high-grade sarcomas of the lower extremities were more prone to local recurrence and, eventually, amputation after LSS. Patients who underwent amputation after LSS developed a high rate of distant organ metastasis during follow-up and had reduced survival.

HIGHLIGHTS

  • The most common causes of amputation after limb-salvage surgery (LSS) were local recurrence and prosthetic infection.

  • Large, deeply located, and high-grade sarcomas of the lower extremities were more commonly associated with local recurrence and, eventually, an amputation after LSS.

  • Patients who underwent amputation after LSS developed a high rate of distant organ metastasis during follow-up and had reduced survival.

Footnotes

Ethics Committee Approval: Ethics committee approval was received for this study from the local ethics committee of Marmara University School of Medicine (09.2020.8).

Informed Consent: N/A.

Author Contributions: Concept - Ö.B., B.E.; Design - Ö.B., F.S.; Supervision - E.Ş., B.E.; Materials - B.E.; Data Collection and/or Processing - Ö.B., O.Y.; Analysis and/or Interpretation - Ö.B., F.S., Ö.S.; Literature Review - Ö.B., F.S., Ö.S.; Writing - Ö.B., B.E.; Critical Review - E.Ş., B.E.

Conflict of Interest: The authors have no conflicts of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

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Indications of amputation after limb-salvage surgery of patients with extremity-located bone and soft-tissue sarcomas: A retrospective clinical study (2024)

FAQs

What happens after limb salvage surgery? ›

What happens after limb salvage surgery? Most people will need extensive physical rehabilitation after limb salvage surgery. A physical therapist will work with you to exercise your limb and restore its range of motion to the extent possible.

What is the new limb salvage procedure? ›

Limb-salvage surgery helps preserve the limb by removing the part of the bone involved with the tumor and some of the tissues that surround it. The bone is replaced with an implant, which can be either a bone graft or a metal prosthesis.

What is the difference between limb salvage and limb-sparing surgery? ›

Limb salvage, also known as limb-sparing surgery, is a surgical procedure aimed at preserving a limb that is at risk of amputation due to severe trauma, infection, or cancer.

What is limb salvage vascular surgery? ›

A limb salvage procedure may involve various techniques to restore blood flow to a limb. It involves a minimally invasive procedure called angioplasty, which uses tiny balloons and a stent (tube) made of mesh to open up the narrowed blood vessels. You will be asleep during the procedure.

What are the indications for limb salvage surgery? ›

Indications for limb salvage surgery are anticipated tumor removal with adequate margins, along with an anticipated acceptable functional and cosmetic result. Relative contraindications are pathologic fractures, neurovascular encasement, and a poorly placed biopsy tract.

What is the success rate of limb salvage surgery? ›

In patients without metastasis at surgery, the metastasis-free and overall survival rates at 5 years following LSS vs. amputation were 75% vs. 58% (p = 0.162) and 71% vs. 55% (p = 0.516), respectively.

How long after losing a limb can you get a prosthetic? ›

Starting Out With a Prosthesis

If the prosthesis is a traditional one that uses suction to attach to your remaining limb, you will likely receive it after your amputation site has healed, which usually takes about six weeks. If the site heals well and there are no complications, you can begin to use your prosthetic.

What does limb salvage primarily depend on? ›

In patients who are stable but have a severely injured limb, the decision for limb salvage or amputation primarily depends on the level of soft tissue injury sustained, as well as neurovascular damage impacting the long-term outcomes.

How long does it take to recover from limb surgery? ›

Generally, patients will need to spend a few days in the hospital after the surgery and will be on crutches for several weeks afterward. As their nerves adjust to the changes, patients are advised to avoid weight-bearing activities for at least three months after surgery.

What is limb-sparing surgery for chondrosarcoma? ›

It is also sometimes called limb salvage surgery. The surgeon removes the area of bone containing the cancer and may replace it with a: metal implant called a prosthesis. replacement bone either from another part of the body or from a bone bank.

What is an example of salvage surgery? ›

Salvage surgery is defined as surgical resection of persistent or recurrent primary lung cancer after previous local treatment without surgery, in case of urgency such as hemoptysis, bronchial stenosis, abscess cavity or empyema, or as therapy for chronic bronchopleural or bronchopulmonary fistulas (Table 1).

How long is recovery from bone lesion surgery? ›

Most people stay in the hospital for about a week. Before you can go home, your wound needs to look like it's healing well. This should be about a week after your operation. But it may take months for your bone to fully heal.

What is the recovery time for limb salvage surgery? ›

Rehabilitation following a limb salvage surgery can take time. Wounds can heal in about two weeks, but recovery can take weeks or even months if muscles, nerves, or bones are affected. Nerve endings grow very slowly, at a rate of about 1mm per day, and it can take up to a year for nerve recovery to occur.

What is the most difficult vascular surgery? ›

Branched Arch Aneurysm Repair

Aneurysms along the aortic arch are rare and are the most complex to treat, largely because the arterial branches that supply blood to the brain and upper extremities are attached along the aortic arch.

Can you walk after vascular leg surgery? ›

Arterial Procedure Recovery

Bruising is common for the first few days before gradually improving. Walking is encouraged right away with slow increase. Avoidance of sitting or standing for long periods is necessary and when laying, the legs should be elevated.

Is limb salvage surgery painful? ›

Limb salvage surgery takes three to four hours. You'll receive general anesthesia, so you'll be asleep and won't feel any pain. Your doctor will take a vein from your leg or another area of your body to create a bypass around your occluded vessels. If taking a vein isn't an option, an artificial bypass may be used.

What do they do with amputated limbs after surgery? ›

Patients often have the option to donate their limbs to science, however if they choose not to, hospitals will dispose of limbs as medical waste. Typically, once disposed of, body parts are incinerated. This is important to reduce the chances of contamination, but it is also done on parts with no known pathogens.

What is the success rate of limb reattachment? ›

What is the success rate of replantation? The overall success rate of limb replantation is approximately 83.2%. The type of injury plays a key role in determining the outcome. For example, guillotine amputations have a better prognosis than crush amputations.

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