Patients with high-grade osteosarcoma who have been previously misdiagnosed as benign lesions or infection and accordingly been treated by curettage, internal fixation or drainage present a challenge in deciding the most appropriate treatment plan. Since one of the contraindications of limb salvage is the inability to achieve a wide surgical margin, there has been a tendency to treat these patients by amputation. Due to contamination by previous surgeries, limb salvage surgery was thought to be associated with a higher risk of local recurrence.

The aim of this study was to evaluate the oncologic outcome following limb salvage surgery done for high-grade osteosarcoma patients who were initially treated inadequately by curettage, internal fixation or drainage.

The study included 24 patients (14 males and 10 females) with an average age of 19 years (range 7 to 39 years). All the patients had high-grade osteosarcoma of the extremities. Seven were located in proximal tibia, six distal femur, four proximal humerus, three proximal femur, two distal tibia, one distal radius and one fibula. 14 patients were previously diagnosed as benign lesions and treated by curettage. 5 patients were diagnosed as regular fracture and internally fixed. 5 patients were diagnosed as osteomyelitis and treated by drainage. The patients were staged then treated by neoadjuvant chemotherapy and limb salvage surgery. The average time between the initial procedure and the limb salvage procedure was 7 months (range 3 to 36 months). A wide resection margin was achieved in all patients.

The average follow up period was 40 months (range 18 to 110 months). Local recurrence occurred in three patients (12.5%). Three patients developed chest metastases and one patient developed bone metastases.

We conclude that patients who had an inadequate surgical procedure prior to the diagnosis of a high-grade osteosarcoma could still be treated by neoadjuvant chemotherapy and limb salvage surgery without a significant increased risk of local recurrence and chest metastases.

Osteosarcoma is the most common bone tumour of the paediatric age. Long time survival can be reached in 70% of patients when metastatic disease is absent at presentation. But in spite of aggressive chemotherapy regimens, about 30% of patients die of the disease.

This retrospective study was carried on 120 patients with primary non-metastatic osteosarcoma of the extremities, attending at Cairo University Hospitals (Faculty of Medicine and National Cancer Institute) between January 1993 and June 2006. The patients’ functional outcome was evaluated according to the Musculoskeletal Tumor Society Functional Rating System.

All patients have undergone surgical resection of the tumour and limb salvage. They have received different chemotherapy regimens depending on the time of entry to the study. Four patients were treated according the Osteosarcoma Group Study I (OSGI): six courses of adjuvant cisplatin and doxorubicin. Twenty patients received OSGII: 2 neoadjuvant and 4 adjuvant courses of cisplatin and doxorubicin. Twenty-nine patients received OSGIII: high-dose methotrexate, ifosfamide, doxorubicin, and cisplatin. Sixty-seven patients received OSGIV: high dose cisplatin, ifosfamide, doxorubicin and a cardioprotective agent. Patients with limb salvage surgery were divided into 3 groups: mobile joints (33 patients), fused joints (75 patients) and rotation plasty (12 patients).

The 5-year event free survival and overall survival for the 120 patients were 70.9 % and 71.3% respectively at median follow-up of 54.5 months and a range of 5–153 months. Functional outcome for available patients according to MST rating system was < 70% in 34 patients and > 70 % in 86 patients. There was not a statistically significant difference between survival and different prognostic factors (age, sex, tumour site, tumour size, tumour necrosis, pathology and time of chemotherapy). Only serum LDH and alkaline phosphatase were statistically significant when correlated with survival.

The results of this study seem to be in accordance with other studies in the literature.