Purpose: Amputation is often proposed for malignant tumours of the distal tibia. The purpose of our study was to report outcome and complications after conservative treatment of osteosarcoma of the distal tibia.

Material and methods: Eight patients, four boys and four girls aged 8 – 16 years (mean 12 years) were managed conservatively with high-dose methotrexate chemotherapy for osteosarcoma of the distal tibia between 1983 and 1998. Wide resection was performed in all cases and one patient had a lung metastasis. Mean length of resection was 13 cm (9–19). Tibiotalar reconstruction arthrodesis was performed in seven patients. Tibial grafts and a centromedullar nail associated with fibulotalar arthrodesis with screw fixation were used in four patients. Plate fixation was used in two, and one patient had a cement spacer while waiting for biological reconstruction. After surgery, the patients were immobilised in a plaster cast for three to six months. Weight bearing began two to four months after surgery.

Results: Resection was wide in four cases, marginal in three , and contaminated in one. Four patients responded well to chemotherapy and four responded poorly. Outcome was assessed at a mean follow-up of 5.5 years (2–17 years). At last follow-up, six patients were in remission, and two had died, including one after local recurrence despite amputation. Three patients had a deep infection which cured in all three without surgery. Two revisions were required in one patient with nonunion before achieving a solid union. All the patients who had a tibiotalar arthrodesis progressively developed nearly normal “ankle” function subsequent to progressive sub-talar hypermobility. The mean MSTS score was 27.7/30 (range 22 – 30).

Discussion: Conservative management of osteosarcoma of the distal tibia appears to be feasible and provides excellent functional results despite an important risk of infection. Wide surgical margins requires a good response to chemotherapy. In case of doubt, reconstruction must avoid contaminating the rest of the tibia in order to allow secondary amputation if needed.

Purpose of the study: Advances in chemotherapy protocols over the last 20 years have considerably improved the prognosis and functional outcome in patients with osteogenic sarcoma. We report here the results of a cooperative study conducted under the auspices of the French Society of Pediatric Oncology (SFOP). Twenty-nine oncology centers participated in this retrospective national multicentric study.

Materials and methods: The study included 15 .3 patients with osteogenic sarcoma of the limb who were treated by the OS87 protocol with conservative surgery between 1987 and 1994. The OS87 protocol consisted in conservative or nonconservative surgery combined with pre- and postoperative chemotherapy. The following inclusion criteria were used: age under 20 years, tumor localization in a limb (pelvis and spine excluded), no metastasis at diagnosis, biopsy proven osteogenic sarcoma.

Results: Mean age at diagnosis was 13 years. The knee localization predominated (80 p. 100). 82.5 p. 100 of the patients had grade IIB disease (Enneking classification). For the 187 patients included in the protocol surgery was nonconservative in 20 p. 100 of the cases and conservative in 80 p. 100. The choice of the surgical technique (arthroplasty, allograft, autograft, resection without reconstruction) depended on the patient’s age and school situation. Data analyzed here concerned only those patients who had conservative treatment. Mean follow-up was 64 months. The actuarial survival curve plateaued at 71 p. 100 at more than 6 years. Early and late complications were numerous and variable (mechanical, infectious, local recurrence). Secondary amputation was required in 10 p. 100 of the patients. The overall functional outcome of the preserved limbs was nevertheless good with rapid restoration of self-sufficiency despite major surgery and a high number of reoperations (about 65 p. 100 of cases).

Discussion: In light of the frequency and the seriousness of the complications, these results are modest. Patients and family should be advised of the risk, particularly the risk of secondary amputation which may be required early due to contaminated excision or at mid term due to major non-cancerological complications. As survival has been improved, functional capacity must be preserved for several years. This orients surgery towards more “biological” reconstruction which can provide greater longevity than arthroplasty.