Minimally invasive plate osteosynthesis: Where is the evidence?

Limb salvage prostheses can vary in complexity from focal resurfacing implants in joints to partial and complete joint replacement to large spacer endoprosthetic devices with or without arthrodesis to endoprosthetics coupled with exoprosthetics. Limb salvage covers a range of strategies used to avoid amputation when managing tumors of the appendicular skeleton and other severe orthopedic problems, such as congenital anomalies, traumatic and degenerative conditions. Full limb amputation remains the standard of care for definitive local excision of limb tumors in dogs and cats and also remains a common treatment for what is considered to be irreparable trauma. Neurogenic or vascular compromise are also significant indicators for full limb amputation in dogs and cats. For the current abstract the focus is on limb salvage using massive endoprostheses and combination endo-exo-prostheses for limb preservation in patients affected by severe trauma to the distal limb or appendicular neoplasia. Other strategies used to spare limbs with tumours include tumour excision and replacement of the defect with a (vascularized) autograft or an allograft, stereotactic radiation, bone transport osteogenesis, tumour sterilization through pasteurization or irradiation, and complex soft tissue excisions.

Limb salvage strategies should only be considered under the conditions that the procedure improves the patient’s quality of life and that median survival is no less than after limb amputation in the case of appendicular tumour patients. However, a risk of local tumour recurrence would remain with limb salvage but not with limb amputation. Also, limb salvage procedures should alleviate the pain originating in the region affected by the tumour. Limb sparing is generally sought in response to a subjectively- determined fear of loss of mobility or in response to an emotional reluctance to amputate a limb. Factors that influence mobility include size, fitness, age, comorbidities (osteoarthritis, neurologic deficits), body condition, and personality. There are no validated tests that let clinicians predict mobility after amputation or limb sparing. These tests should be developed and validated. Also, there are no validated tests that allow the objective assessment of quality of life throughout the management of tumours with limb spares. In the absence of such tests, clinicians cannot objectively justify limb sparing procedures by comparison with full limb amputation or compare their relative effectiveness in improving quality of life.  [...]