Sarcoma is a malignancy of mesenchymal and neuroectodermal tissue, and as such, may arise in any location in the body. It is a rare tumour accounting for less than 1 in 1000 cancers and occurs with an incidence of 1.7–2 per 100000 head of population. Disease free survival following treatment of sarcoma has increased significantly over the last 20–30 years and five year survival for primary bone malignancies is approximately 75–80% and that for soft tissue sarcomas is approximately 70%. Early attempts at limb sparing surgery was characterised by surgery with narrow margins, complicated incisions and substantial soft tissue bruising. Not surprisingly, the risk of local recurrence was high, but this was attributed to the nature of sarcoma rather than technique, and amputation became the treatment of choice for sarcoma. In the mid 1970’s, the importance of surgical margins was recognised and guidelines were established for achieving oncologic surgical margins. Intralesional and marginal margins alone were regarded as inadequate, while wide and radical margins were acceptable for achieving local control of disease. The advent of magnetic resonance imaging improved the level of tumour delineation and allowed more accurate preoperative planning. This together with modern chemotherapy and radiotherapy increased the potential for limb sparing surgery. Reconstruction following tumour resection is an exciting opportunity to protect the function of the limb and the mobility and independence of the patient. There have been a variety of techniques described and these involve either biological, prosthetic or a combination of these options. Reconstructions may be mobile or rigid. Mobile reconstructions frequently utilise prosthetic joints, but at other times pseudarthroses may function similarly, e.g. hip, shoulder. Osteoarticular allografts are also used to maintain joint function following tumour resection. Prosthetic joints incorporate advances in articulation and fixation to improve longevity as many of these devices are implanted into younger patients than normally anticipated for arthroplasty, and these joints are thus, exposed to an increased risk of wear and loosening. Osteoarticular allografts are prone to degenerative changes as well as graft disintegration and infection. Allograft prosthetic composites aim to reduce the articulation problems and may also assist in fixation of the construct. Biologic reconstructions using vascularised or non-vascularised bone are a useful technique for bridging defects and for replenishing bone stock. Adequate soft tissue coverage is vital following reconstruction. The future of limb sparing surgery will depend on our ability to characterise the biological behaviour of the tumour because this will provide more information on the response of the tumour to treatment, the potential grade of the lesion and thus, its capacity to grown and spread. By understanding the process of tumour progression, we will be able to develop better strategies for treatment. Functional nuclear scanning using isotopes that are metabolised by tumours is a technique that is currently being evaluated as a complementary form of imaging. Chemotherapy has been the cornerstone in the treatment of bone sarcomas, but remains surprisingly disappointing when used for soft tissue sarcomas. Recent meta-analyses have demonstrated only a minimal improvement in disease–free survival with chemotherapy. Novel techniques or agents are required to improve the systemic role of chemotherapy. Patient selection is important and this may relate to their risk of developing systemic spread. Prognostic factors are therefore, important for identifying patients who may be candidates for novel or intensive chemotherapy. Molecular biology is providing an avenue for characterising these tumours but despite the identification of a multitude of distinctive chromosomal abnormalities with their associated gene products, only 2 abnormalities have been shown to be of prognostic significance (19p+ in MFH, and SSX/SYT in synovial sarcoma). Surgeon education is an area where significant advances may be made. Constant reiteration is required to ensure that the principles of proper diagnosis and referral are known. Successful treatment is dependent on knowledge of the criteria for and technique of biopsy, and the principle that the team that will be providing definitive treatment should perform the biopsy. Up to 30% of limbs are sacrificed each year because of inappropriate biopsy or surgery. This figure may be improved upon with greater understanding of the behaviour of sarcomas. A regimented, multidisciplinary approach to the management of bone and soft tissue sarcomas is likely to improve the local and systemic control of this disease

Primary malignant bone and soft tissue tumours often occur in the lower extremities of active individuals including children, teenagers and young adults. Survivors routinely face long-term physical disability. Participation in sports is particularly important for active young people but the impact of sarcoma treatment is not widely recognised and clinicians may be unable to provide objective advice about returning to sports. We aimed to identify and summarise the current evidence for involvement in sports following treatment of lower limb primary malignant bone and soft tissue tumours. A comprehensive search strategy was used to identify relevant studies combining the main concepts of interest: (1) Bone/Soft Tissue Tumour, (2) Lower Limb, (3) Surgical Interventions and (4) Sports. Studies were selected according to eligibility criteria with the consensus of three authors. Customised data extraction and quality assessment tools were used. 22 studies were selected, published between 1985 – 2020, and comprising 1005 patients. Fifteen studies with data on return to sports including 705 participants of which 412 (58.4%) returned to some form of sport at a mean follow-up period of 7.6 years. Four studies directly compared limb sparing and amputation; none of these were able to identify a difference in sports participation or ability. Return to sports is important for patients treated for musculoskeletal tumours, however, there is insufficient published research to provide good information and support for patients. Future prospective studies are needed to collect better pre and post-treatment data at multiple time intervals and validated clinical and patient sports participation outcomes such as type of sports participation, level and frequency and a validated sports specific outcome score, such as UCLA assessment. In particular, more comparison between limb sparing and amputation would be welcome

Aims. Surgical limb sparing for knee-bearing paediatric bone sarcoma is considered to have a clinically significant influence on postoperative function due to complications and leg-length discrepancies. However, researchers have not fully evaluated the long-term postoperative functional outcomes. Therefore, in this study, we aimed to elucidate the risk factors and long-term functional prognosis associated with paediatric limb-sparing surgery. Methods. We reviewed 40 patients aged under 14 years who underwent limb-sparing surgery for knee bone sarcoma (15 cases in the proximal tibia and 25 in the distal femur) between January 2000 and December 2013, and were followed up for a minimum of five years. A total of 35 patients underwent reconstruction using artificial materials, and five underwent biological reconstruction. We evaluated the patients’ postoperative complications, survival rate of reconstruction material, and limb, limb function, and leg-length discrepancy at the final follow-up, as well as the risk factors for each. Results. Complications were observed in 55% (22/40) of patients. The limb survival and reconstruction material rates at five and ten years were 95% and 91%, and 88% and 66%, respectively. Infection was the only risk factor in both survivals (p < 0.001, p = 0.019). In the 35 patients with limb preservation, the median International Society of Limb Salvage (ISOLS) score at the final follow-up was 80 (47% to 97%). Younger age (p = 0.027) and complications (p = 0.005) were poor prognostic factors. A negative correlation was found between age and leg-length discrepancy (R = −0.426; p = 0.011). The ISOLS scores were significantly lower in patients with a leg-length discrepancy of more than 5 cm (p = 0.005). Conclusion. Young age and complications were linked to an unfavourable functional prognosis. Leg-length correction was insufficient, especially in very young children, resulting in decreased function of the affected limb. Limb-sparing surgery for these children remains a considerable challenge. Cite this article: Bone Jt Open 2024;5(10):868–878

Objectives: Description of early results using a new modality in musculoskeletal oncology. Introduction: Radiofrequency as a malignant tumor ablative modality has been employed during the last decade in liver tumors. Extra-hepatic application in malignancies is new and its indications are not precisely defined. It has been used for more than ten years for osteoid osteoma ablation. Radiofrequency allows destruction of a precise sphere around the application tip. Ablation efficiency is monitored by the change in tissue conductance following tissue necrosis. Methods: 10 patients scheduled to undergo limb sparing surgery were included. During the pre-operative angiography and embolization, tumors were treated by radio-frequency ablation. The precise location of the needle electrode was defined by real-time ultrasonography. The relation of the needle tip to large blood vessels was monitored by comparison of ultrasonography to angiography. Thus, precise ablation of the tumor tissue was possible without risk to the neurovascular bundle. Results: Tumor necrosis was uniform in the center of the ablative sphere and declined to 60 percent in the periphery. No complications were encountered. Discussion: This method appears to allow further shrinkage of the tumors prior to limb sparing surgery. This technique is rapid and does not require delay of surgery, as does isolated limb perfusion or neo-adjuvant chemotherapy. The procedure can be performed in sedated patients, thus obviating the need for general anesthesia prior to limb sparing surgery. It can be employed in areas were isolated limb perfusion is not anatomically feasible such as the pelvis. Further studies are required in order to better define the role of this technique as compared to intra-arterial chemotherapy or isolated limb perfusion

The influence of advancements in imaging and chemotherapy on patient with dedifferentiated chondrosarcoma was determined. There were forty-two cases in which twenty-seven patients received adjuvant therapy. Median survival was eight months and five-year survival was 4.8%. There was no statistical difference (p=0.62) in survival between patients who did and did not receive chemotherapy, had wide versus radical resection, or had limb sparing versus sacrificing procedures. There were no statistically significant differences between patients treated prior to 1986 and those subsequently. Despite advances, dedifferentiated chondrosarcoma continues to carry a poor prognosis. The routine adjuvant chemotherapy in this population should be questioned. The long-term survival for patients that presented with dedifferentiated chondrosarcoma has historically been poor. A large clinical series has not been analyzed in the era of modern diagnostic and treatment modalities. The current study was performed to look at the influence of advancements in imaging and chemotherapy on patient outcome. A retrospective chart review of all cases of patients presenting with dedifferentiated chondrosarcoma at our institution from 1984–2000 was performed. This was done as an extension to a study published in 1986 prior to the era of modern chemotherapy. There were forty-two cases in twenty-five men and seventeen women of average age fifty-six (range twenty-four-eighty-three years). MSTS grades at presentation were IIA(5), IIB(27), and III(10). Three patients underwent biopsy only, nineteen had limb sacrificing surgery, and twenty had limb sparing procedures. Surgical margins were intralesional in three, marginal in two, wide in twenty, and radical in fourteen. Twenty-seven patients received adjuvant therapy (twenty-two chemotherapy only, two radiotherapy only, three combined therapy). Median survival was eight months and five-year survival was 4.8%. There was no statistical difference (p=0.62) in survival between patients who did and did not receive chemotherapy, had wide versus radical resection, or had limb sparing versus sacrificing procedures. There were no statistically significant differences between patients treated prior to 1986 and those subsequently. Despite advances in diagnostic modalities, surgical treatments, and adjuvant therapies, dedifferentiated chondrosarcoma continues to carry a poor prognosis. The routine use of current adjuvant chemotherapy and its inherent risks and benefits in this population should be questioned

To elaborate upon the complex variety of successful reconstructive techniques for limb salvage surgery for the management of aggressive juxta-articular and peri-acetabular bone tumors. Limb sparing surgery, while complex, continues to gain wider acceptance among an increasing number of highly specialised musculoskeletal oncology surgeons. The collective experience of the Musculoskeletal Sarcoma Group at The University of Calgary has utilised a variety of limb and joint salvage techniques in its armamentarium for reconstruction of such cases. Whether malignant or benign, aggressive lesions occur at or near the joint resulting in marked subchondral bone destruction or pathologic fractures. comprehensive stepwise plan can result in a stable, pain free and functional joint with limb sparing. The author has utilised local tumor removal and cementation with polymethylmethacrylate with and without secondary internal fixation. ome cases have been amenable to massive osteoarticular allografts, and more recently, tumor endoprostheses. The North American experience with massive oncology prostheses is growing, resulting in increased opportunities for limb and joint salvage surgery with decreased morbidity and complications. his presentation will review the experience of the principal author’s work in limb and joint-sparing bone tumor surgery over the past 18 years

Introduction: Radical excision and amputation are the surgical options for advanced soft tissue tumours (STS) of the limbs. The sheer size of these advanced tumours in relation to the limb makes limb sparing surgery difficult. The rate of positive margins is high and further management options are quite limited. Patients & Methods: We have identified 17 patients (13 males, 4 females) with sarcomas with skin changes at presentation, including recurrences and primary referrals. The average age was 67 (37–83) years. 11 patients had lower limb tumours and 6 had upper limb tumours. All patients were managed either with radical excision or amputation. Post op radiotherapy and chemotherapy was used s adjuvants when appropriate. All patients were followed up with regular clinical and radiological assessments for recurrences and metastases. The results of adequacy of clearance, recurrences, metastases and overall survival are presented. Results: The follow-up was an average of 30 (7–120) months. Two patients had primary amputations and 15 had wide excision. Four patients had distant metastases at the time of referral. Positive margins were identified in 8 of the 17 patients after primary surgery. 5 patients had a single recurrence and 3 patients had two recurrences. Eight patients needed revision surgery (3 amputations/5 wider excisions) for a positive margin or a recurrence. A total of 8 patients had metastases by 1 year. Overall disease free survival in this cohort was 20 (3–41) months. Conclusion: We encountered a very high rate of positive margins with high morbidity which seems quite common after limb sparing surgery in fungating STS. Amputation comparatively attains better local disease control but probably does not affect the overall survival

Aims. To report the outcome observed in 34 dogs with non metastatic distal radial osteosarcoma (OSA) treated by a combination of adjuvant chemotherapy and limb-sparing surgery. Limb-sparing procedures were based on the use of a frozen bone cortical allograft (group A; 18 cases) and of a pasteurised tumoral autograft (group B; 16 cases), respectively. Methods. In group A, limb-sparing procedure was performed using a fresh-frozen cortical allograft from a bone bank. In the group B, the bone graft was realized from the excised tumoral segment after its pasteurisation at 65A1C for 40 minutes. Adjuvant chemotherapy (cisplatin or cisplatin and doxorubicin) was administered in all dogs. Results. In group A, mean and median survival times were 478-266 days, respectively (range 80–2611 days). Overall survival was 78% at 6 months, 35% at 12 months, 23% at 18 months and 19% at 24 months. Lung metastasis occurred in 10 cases (55%). Observed complications were local recurrence (28%), graft infection (39%) and implant failure (11%). In group B, mean and median survival times were 533-368 days, respectively (range 137–1944 days). Overall survival was 100% at 6 months, 57% at 12 months, 45% at 18 months and 20% at 24 months. Metastasis were observed in 7 dogs (44%). Complications were local recurrence (12%), graft infection (44%) and implant failure (19%). Limb function was good in 72% (group A), and 92% (group B) of the dogs, respectively. Conclusions. Limb-sparing techniques with bone grafts represent an alternative to amputation in the treatment of selected cases of distal radial osteosarcoma. Limb sparing techniques are not free of complication (infection, implant failure, recurrence) if compared to amputation. The latter represents the elective option in most cases of appendicular OSA and is usually free of complication. Comparing the two treatment groups, pasteurised bone autograft derived from the tumoral bone segment represents an effective alternative to cortical bone allograft coming from a bone bank, considering the difficulties encountered in finding donor dogs and national legal limitations on establishing a canine cortical bone graft bank. Alternative limb sparing procedures (metallic implant, Ilizarov) will be also discussed

Introduction and Aims: Improved survival has motivated aggressive surgery with musculoskeletal tumors. Pelvic resection is challenging because of the constraints of adjacent vital anatomy, and the considerable impact on limb and visceral function. The aims of this study was to assess the functional, oncologic and surgical outcomes following resections of the bony pelvis. Method: Between 1996 and 2003, 49 patients underwent tumor resections of the pelvic ring. The mean age was 43 (range 15–72) years. There were 44 primary (36 bone, nine soft tissue) and five secondary tumors. Of the bone tumors, there were six osteosarcomas, five Ewings sarcomas, 12 chondrosarcomas and 13 others. Of the soft tissue tumors, nine were of neural origin. Tumor locations included the ilium, periacetabulum, pubic bones, sacrum or combinations of these. Neoadjuvant chemotherapy (seven patients) and pre-operative radiotherapy (eight patients) were also used. Function was assessed using the American Musculoskeletal Tumor Society Functional scoring system. No patient had metastases at presentation. Results: Surgery – There were 40 limb sparing resections and nine hindquarter amputations. The surgical margins were intralesional (four), marginal (12), wide (28) and radical (five). Of the limb sparing surgery, prosthetic reconstructions were used in nine patients, biologic reconstructions in seven patients a combination of biologic and prosthetic reconstructions in three cases and no reconstructions in the others. The mean operating time was five (range 1.5–10) hours. The mean intra-operative blood loss was 10 (range 2–26) units. The average length of stay was 22 (range 2–110) days. Fifty percent of patients developed acute complications. Survival – There was one intra-operative death. There were nine local recurrences and 16 metastases. Death from disease occurred at a mean time of 13 (range 1–51) months. Mean follow-up was 28 (range 1–90) months. Functional assessment – Hind quarter amputation and periacetabular resections had the worse functional outcome. These accounted for almost 40% of all cases. Surprisingly, patients with periacetabular resections had the best score for emotional acceptance. Conclusion: Pelvic resections are complex, demanding and accompanied by a high complication rate. Surgery significantly affects functional outcome. Disease control is similar to limb tumors and medium to long-term survival is possible. Emotional acceptance of surgery in survivors was surprisingly high. Major pelvic resection for malignancy appears justifiable

Limb salvage in musculoskeletal tumor surgery may be complicated by infection. With the advent of modern techniques and medical management limb sparing surgeries can be considered as an alternative to ablation. Between 1992 and 2014, 17 patients were treated for infected megaprostheses after being surgically treated for musculoskeletal tumors. There were nine females and eight males. The mean time from the index procedure until infection was 30 months. Following radical debridement, the resultant skeletal defect averaged 30 cm. Patients were treated with local antibiotics in polymethyl methacrylate (PMMA) spacers and endoprostheses as well as IV antibiotics for a minimum of six weeks followed by oral antibiotics for an additional six weeks. The initial tumor procedure involved the femur in eleven patients, the tibia in two, the acetabulum in one, the humerus in two, and the ulna in one. Patients had repeat cultures before two-stage reimplantation when their WBC, ESR, and CRP returned to normal. Patients were reimplanted when final cultures were negative. Thirteen patients were treated using a two-stage protocol with customized intraoperative antibiotic impregnated PMMA spacers including intramedullary nails for a mean of 10 months and the other four patients had a one-stage procedure. These four patients included two patients with a total femur replacement and two patients with an allograft-prosthetic composite of the proximal humerus and ulna. The organisms cultured were gram positive in 14 cases, mixed gram positive and negative in one case, and two patients had no growth on cultures but histologic evidence of acute infection. Reimplantation was successful in 13 patients after the initial procedure (76%). Four patients had recurrent infections. One of these patients was successfully reimplanted after a one-stage procedure, two had a second two-stage procedure and have retained their spacers, and one had an amputation. Successful limb salvage in regards to infection control occurred in 14/17 patients (82%). One additional patient required an amputation for an oncologic complication (local recurrence), so the overall limb salvage rate was 13/17 (76%). Patients with megaprosthetic infections following limb salvage treatment for musculoskeletal tumors do not have to be uniformly subject to amputation. Radical debridement and appropriate antibiotics in conjunction with custom spacers followed by selective one- and two-stage reimplantation results in successful limb salvage in 82% of patients. This result is similar to other reports despite the large size average defects

Introduction. Telangiectatic osteosarcoma (TOS) is a rare subtype of osteosarcoma. We review our experience to characterize its prevalence, treatment, relapse and survivorship at long term follow-up. Methods. Eighty-seven patients aged from 4 to 60 years (mean 20 years), were treated from 1985 to 2008. Lesions affected the femur (38), humerus (20), tibia (19), fibula (4), pelvis (3), foot (2) and radius (1). Eight patients had metastatic disease at diagnosis. Seventy-eight patients were treated with neoadjuvant chemotherapy with three or more drugs according to different protocols, nine had surgery as first treatment. Limb salvage surgery was performed in 71 cases, amputation in 14 and rotationplasty in one. One patient died before surgery. Prognostic factors were evaluated with Kaplan-Meier analysis. Results. At a mean follow-up of 8 years, overall survival was 81%, 65% and 65% at 2, 5 and 10 years respectively. Fifty-two patients were disease-free, three were alive with disease, twenty-nine died with disease and three died of other causes. Thirteen local recurrences were observed. Twenty-three patients developed lung (20) or bone (3) metastases. Pathologic fracture did not significantly influence survivorship. Prognostic influence of age of the patients was evaluated at three different cut-off (15, 20 and 25 years-old): younger patients had better survivorship, without statistical significance. Induced necrosis according to Huvos’ classification was significant at both univariate and multivariate regression Cox analysis (p=0.0001). Conclusion. TOS does not have a poor prognosis as previously reported in the literature. A high percentage of patients can be cured with neoadjuvant chemotherapy and surgery. In most patients, limb sparing surgery is possible and safe

Aims: Limb sparing surgery, for selected cases of long bone primary malignancy, may be accomplished with the use of large prostheses. Conventional joint implants are known to release metal ions by corrosion or wear. The aim of this study was to determine if a specialist group of patients had elevated serum metal levels. Methods: Over a 12 month period, 20 patients who had undergone previous surgery were recruited from a bone tumour clinic. A 10ml venous blood sample was obtained and analysed for trace metals using a previously published mass-spectrometry technique. Results: Eight children (mean age 14.5 years) and 12 adults (mean age 46.5 years) were recruited a mean of 54 months and 86 months following surgery, respectively. Trace metal (aluminium, titanium, cobalt) elevation was observed in 5/8 (63%) paediatric cases and 6/12 (50%) adult cases. Three of the adults had signiþcantly raised levels, (≤ 50 times), and had undergone revision surgery for loosening. There was no observed implant loosening in the paediatric group. Conclusions: This small sample has demonstrated that many patients with long-term large tumour implants have trace metal levels below laboratory detection. Signiþcant elevation of metal levels in adults was associated with loosening or wear of implants. A signiþcant proportion of paediatric cases had slight elevations, but the signiþcance of this is unknown at present

Background: The incidence of osteosarcoma varies considerably with age and preschool children are extremely rarely affected. This study was conducted to investigate presentation, treatment, and outcome in very young children with osteosarcoma. Patients and methods: The authors retrospectively analyzed the data of 2706 consecutive COSS patients with newly diagnosed high-grade osteosacroma of bone and identified 28 patients (1.0%) aged less than five years at diagnosis. Demographic, diagnostic, tumor, and treatment related variables; response and survival data of these 28 were analyzed. Results: Of the 28 (male, N=16; female, N=12) toddlers, 27 presented with high-grade central osteosarcoma of an extremity (femur, N= 12; humerus, N=10; tibia, N=5) and one with a secondary osteosarcoma of the orbit. The size of primary extremity tumors was large (≥ 1/3 of the involved bone) in 20/27 evaluable patients. Primary metastases were detected in 4 children. All patients received multiagent chemotherapy, and 13/20 analyzed tumors responded well (> 90% necrosis) to neoadjuvant chemotherapy. Limb sparing surgery was performed in 11, ablative procedures were performed in 14, and no local surgery was performed in two patients with extremity tumors. With a median follow-up of 3.8 years (6.2 years for survivors), 13 patients were alive (CR1, N=12; CR3, N=1). Four patients never achieved a complete remission and 12 developed recurrences (local, N=3; metastatic, N=8; site unknown, N=1); and 15 of these 16 patients died. Five-year overall and event free survival probabilities were 50% (SE 10%) and 46% (SE 10%). Better survival was correlated with good response to chemotherapy. Conclusions: Osteosarcoma is extremely rare in pre-school children. These young patients often have large tumors which may require mutilating resections. Prognosis may be poorer than in older patients

Limb-sparing surgery has become the preferred surgical treatment of malignant bone tumours of the knee. In patients with intra-articular extension of their tumour, extra-articular limb sparing surgery can prevent the knee from amputation. In a retrospective study between January 1985 and December 2007, we performed 34 extra-articular tumour resections of the knee-joint for a bone- or soft tissue tumour in the distal femur or proximal tibia with (suspect) intra-articular tumour extension into the knee on MRI. Contra-indications were extension of the tumour into the extensor mechanism and/or tumour involvement of the neurovascular bundle. Osteosarcoma (23/34) was the most common primary malignancy. Mean age was 36 years (17–70) and the mean follow up was 9 years (1–19). Patient survival rates at 5 years and 10 years are 78% and 58% respectively, mean patient survival was 47 months (8–211). In 12 (35%) patients, the primary implanted prosthesis failed during follow up. Prosthetic survival rates including minor revision surgery were 63% at 5 years and 36% at 10 years. Six (18%) patients had local recurrence of their malignancy, 5 of them in the popliteal fossa. Local recurrence was significantly correlated with marginal margins (P< 0.05). Fifteen patients had major complications (44%) mainly deep infection in proximal tibia resections and aseptic loosening in distal femur resections. Aseptic loosening was significantly correlated with non HA-coated stems (P< 0.05). Functional outcome scores according to MSTS (mean 81, (65–93)) and TESS (mean 85, (56–98)) of survivors are good. Our results suggest that extra-articular tumour resections of the knee-joint can provide a functional endoprosthesis and can be an alternative for primary amputation. However it is a technical demanding procedure with acceptable local recurrence and high complication rates in patients with, in general, poor survival

Over a five year period 50 patients required combined orthoplastic care out of 987 patients presenting with bone and soft tissue tumours. Thirty men, mean age 51 years, had their treatment reviewed at a mean follow up of 23 months (3–54 months) post surgery. All surviving patients completed the Toronto Extremity Salvage Score. There were 23 bone and 27 soft tissue sarcomas, 4 were Enneking stage I, 41 stage II and 5 stage III. All tumours were removed by wide resection to achieve microscopically clear margins in 49. 9 endoprostheses were inserted. Soft tissue reconstruction involved 9 local flaps, 13 distant flaps (mainly muscle) and 8 free flaps (including 3 composite osseous flaps). 20 patients received adjuvant radiotherapy and 14 patients received chemotherapy. Two endoprosthetic replacements required surgery for infection, one distant lap and one free flap required further surgery (6%). The mean disease free interval was 29 months (2–49 months). There were 6 deaths and pulmonary metastases occurred in a further 8 patients. Within this study period there was one episode of local recurrence, but no local recurrence in the group that had radiotherapy. 77% of surviving patients completed the Toronto Extremity Salvage Score and good to excellent function was seen in most cases. Combined orthoplastic approach facilitates limb sparing surgery and early adjuvant radiotherapy

Aims

The standard of surgical treatment for lower limb neoplasms had been characterized by highly interventional techniques, leading to severe kinetic impairment of the patients and incidences of phantom pain. Rotationplasty had arisen as a potent limb salvage treatment option for young cancer patients with lower limb bone tumours, but its impact on the gait through comparative studies still remains unclear several years after the introduction of the procedure. The aim of this study is to assess the effect of rotationplasty on gait parameters measured by gait analysis compared to healthy individuals.

Introduction: Both enchondromas and chondrosarcomas are mesenchymal neoplasms which originate from cartilage cells, and they occur mainly in the extremities. Both these tumours are resistant to chemotherapy and radiotherapy, and surgery is the only treatment option. In the last few years limb saving procedures have become the treatment of choice. Intra-operative cryosurgery has been introduced as a local adjuvant therapy for skeletal benign and low-grade malignant tumours. It is applied after curettage of the lesion to destroy any remaining tumour cells, and to enlarge the oncological margin of resection. Since the introduction of cryosurgery as an adjuvans, oncological and functional results of this extremity sparing surgery are significantly enhanced. Patients and Methods: A retrospective study was conducted to evaluate the oncological and functional results, and the complications of cryosurgical treatment. Data were prospectively collected from the tumour register and patient records. Functional scores of the affected limbs were assessed according to the Musculo-Skeletal Tumour Society scoring system. Results: Between 1994 and 2003 123 patients (47 men, 76 women, average age 49 years; range 13–83 yrs) were treated with curettage and cryosurgery for an Enneking stage 3 enchondroma (75 patients) or a low-grade chondrosarcoma (55 patients). The minimal follow up was two years, and the average follow up 50 months (range 24–119 months). At follow up three recurrences had occurred in patients treated for enchondroma. One residual tumour was diagnosed in a patient with chondrosarcoma grade Ib. All patients were treated again with curettage and cryosurgery and disease free at the latest follow-up. Of the 37 complications the most common were a fracture at the surgical site (18), fracture of osteosynthesis (6), 3 wound infection (3), delayed soft tissue healing (3), and transient nerve palsy (3). Functional MSTS scores increased in time to an average of 28 points (94%) at two year follow up. No significant difference in scores were found regarding to localisation of the lesion, age or gender. A significant discrepancy in functional scores was observed between patients who did suffer from one or more complications and patients who did not. Conclusion: We believe that the use of cryosurgery is an excellent adjuvant therapy after curettage to achieve local control of aggressive enchondromas and low grade chondrosarcomas. It avoids the need for segmental resection, making reconstruction of the bony defect easier and therefore results in excellent functional outcome. Due to the initial high fracture rate osteosynthesis at the surgical site is used more often, and weight baring mobilisation is postponed until full consolidation is reached

In the last fifteen years (1990–2005) at our Institution more than 600 patients affected by soft tissue sarcomas of the limbs and superficial trunk were surgically treated. We investigated the outcome and risk factors in a homogeneous group of 112 patients, affected by high-grade soft tissue sarcomas of the limbs (not metastatic at presentation) and treated with limb-sparing surgery, brachytherapy and conventional postoperative radiation therapy. Postoperative chemotherapy was added in one fourth of the cases. The histologic types were liposarcoma (21.4%), leiomyosarcoma (19.6%), synovial sarcoma (17.9%), pleomorphic sarcoma or malignant fibrous histiocitoma (14.3%), fibrosarcoma (9.8%), other histotypes (17%). All the tumors were high-grade (Broders grade 3 or 4). Size of the neoplasm was 10 cm or larger in 8 cases, 6 to 9 cm in 60 patients and 5 cm or smaller in 44 cases. A limb-sparing surgical excision was performed in all the cases; histologically adequate margins were achieved in 96 cases (85.7 %). In 28 cases a myocutaneous or fasciocutaneous flap was necessary for local reconstruction. At an average follow-up of six years, 67 patients (59.8%) were continuously disease-free; 8 patients (7.1%) had presented metastatic disease (in one case combined with local relapse) but were alive with no evidence of disease at last follow-up; 3 patients (2.7%) were alive with metastatic disease; 28 patients (25%) had died with disseminated disease; 6 (5.4%) had died of unrelated causes. Local recurrence occurred in 10 patients (8.9%) requiring an amputation in 2; metastatic disease occurred in 39 patients (34.8%). Four more patients required an amputation for complications different from recurrence: one early amputation for surgery-related complications and three late amputations for radiation-related complications (two not-healing fractures, one unresolvable wound sloughing). Wound sloughing occurred in 12 patients (5 surgery-related and 7 radiation-related). Local control rate, disease-free survival, overall survival and limb salvage rate were examined at 5 and 10 years, aiming also to identify tumor or treatment characteristics with prognostic value for the outcome. The use of brachytherapy is an important option for achieving a significant boost in radiation within the surgical bed. Combined treatment with limb sparing surgery plus brachytherapy and external beam radiation therapy seems to offer satisfactory results in terms of local control and limb salvage survival. The use of myocutaneous or fasciocutaneous flaps is often useful in this kind of surgery, making possible a limb-sparing procedure with adequate oncological margins. New protocols and randomized studies on chemotherapy need to be introduced to improve systemic control and overall survival

CT and MRI scans are complementary preoperative imaging investigations for planning complex musculoskeletal bone tumours resection and reconstruction. Conventionally, tumour surgeons analyse two-dimensional (2-D) imaging information, mentally integrate and formulate a three-dimensional (3-D) surgical plan. Difficulties are anticipated with increase in case complexity and distorted surgical anatomy. Incorporating computer technology to aid in this surgical planning and executing the intended resection may improve precision. Although computer-assisted surgery has been widely used in cranial biopsies and tumour resection, only small case series using CT-based navigation are recently reported in the field of musculoskeletal tumor surgery. We investigated the results of CT/MRI image fusion for Computer Assisted Tumor Surgery (CATS) with the help of a navigation system. We studied 21 patients with 22 musculoskeletal tumours who underwent CATS from March 2006 to July 2009. A commercially available CT-based spine navigation system (Stryker Navigation; CT spine) was used. Of the 22 patients, 10 were males, 11 were females, and the mean age was 32 years at the time of surgery (range, 6–80 years). Five tumours were located in the pelvis, seven sacrum, eight femurs, and two tibia. The primary diagnosis was primary bone tumours in 16 (3 benign, 13 sarcoma) and metastatic carcinoma in four. The minimum follow-up was 17 months (average, 35.5 months; range, 17–52 months). Preoperative CT and MRI scan of each patient were performed. Axial CT slices of 0.0625mm or 1.25mm thickness and various sequences of MR images in Digital Imaging and Communications in Medicine (DICOM) format were obtained. CT and MR images for 22 cases were fused using the navigation software. All the reconstructed 2-D and 3-D images were used for preoperative surgical planning. The plane of tumour resection was defined and marked using multiple virtual screws sited along the margin of the planned resection. We also integrated the computer-aided design (CAD) data of custom-made prostheses in the final navigation resection planning for eight cases. All tumour resections could be carried out as planned under navigation guidance. Navigation software enabled surgeons to examine all fused image datasets (CT/MRI scans) together in two spatial and three spatial dimensions. It allowed easier understanding of the exact anatomical tumor location and relationship with surrounding structures. Intraoperatively, image guidance with the help of fusion images, provided precise visual orientation, easy identification of tumor extent, neural structures and intended resection planes in all cases. The mean time for preoperative navigation planning was 1.85 hours (1 to 3.8). The mean time for intraoperative navigation procedures was 29.6 minutes (13 to 60). The time increased with case complexity but lessened with practice. The mean registration error was 0.47mm (0.31 to 0.8). The virtual preoperative images matched well with the patients' operative anatomy. A postoperative superficial wound infection developed in one patient with sacral chordoma that resolved with antibiotic whereas a wound infection in another with sacral osteosarcoma required surgical debridement and antibiotic. After a mean follow-up of 35.5 months (17–52 months), five patients died of distant metastases. Three out of four patients with local recurrence had tumors at sacral region. Three of them were soft tissue tumour recurrence. The mean functional MSTS score in patients with limb salvage surgery was 28.3 (23 to 30). All patients (except one) with limb sparing surgery and prosthetic reconstruction could walk without aids. Multimodal image fusion yields hybrid images that combine the key characteristics of each image technique. Back conversion of custom prosthesis in CAD to DICOM format allowed fusion with navigation resection planning and prosthesis reconstruction in musculoskeletal tumours. CATS with image fusion offers advanced preoperative 3-D surgical planning and supports surgeons with precise intraoperative visualisation and identification of intended resection for pelvic, sacral tumors. It enables surgeons to reliably perform joint sparing intercalated tumor resection and accurately fit CAD custom-made prostheses for the resulting skeletal defect