Tumors
Tumors are the most frequent cause of amputations due to disease. Tumors represent the most common cause of amputations in the European Surveillance of
Congenital Anomalies (EUROCAT) data system (1).
The highest incidence of malignancy is in the 12-21-year-old age group. Osteogenic sarcoma, Ewing's sarcoma, and the rare rhabdomyosarcoma are responsible for the majority of tumors resulting in amputation (43,44). Unprecedented improvement in survival has occurred with earlier detection and combined therapy (45). Definitive surgery for osteosarcoma depends upon the site of the primary tumor and the extent of invasion or metastasis (46). Surgical removal of the affected bone and the surrounding soft tissue remains the treatment of choice, whether by amputation or limb salvage procedure. Limb salvage with an endoprosthesis can be offered to 90% of children with osteosarcoma (45-47). This procedure, which involves replacing the affected bone with a metal endoprosthesis, is accompanied by orders to prohibit contact sports. Compliance with these orders is often questionable. With the advent of extendable endoprostheses, it has been suggested that children who have undergone this treatment have results that are superior to those who have undergone amputation surgery (48-50).The surgical procedure of choice attempts to obtain a tumor-free margin of 5-8 cm above the proximal limit of the medullary tumor. The decision to proceed with limb salvage or amputation is dependent on the aggressiveness of the tumor, the stage, the responsiveness to neoadjunct therapy, and the likelihood of obtaining tumor-free margins (51-53). The knee poses a challenge for soft tissue sarcomas. Despite complications, the knee may be reconstructed with allografts (54,55).
Chemotherapy has now proven an effective adjunct to surgery. Prior to 1972, only 15% of the children were disease-free and survived with surgery, compared to the 60% to 70% who now survive with surgery and the addition of chemotherapy (56,57). Rehabilitation may be confounded by factors of fatigue and the psychological aspects of combined treatments. Physical therapy emphasizing range of motion, strengthening, and functional activities is important for children with lower-extremity sarcoma after limb salvage surgery (58). Outcomes were similar for ambulation, stair climbing, employment, and psychological adjustment when comparing amputation to limb salvage for surgical management of sarcomas (134, 147).
Amputation of a limb during adolescence, when body image is particularly important, may complicate the completion of tasks required during adolescence (59). Psychological reactions are varied. However, emotional distress was less when pain and functional loss preceded the diagnosis (60,61).