26
Limb Salvage Surgery for Extremity Sarcomas
Henry DeGroot III, M.D. and Bruce Ellison, M.D.
Musculoskeletal Oncology Service
Department of Orthopedics and Physical Rehabilitation
University Of Massachusetts Medical School
Umass-Memorial Medical Medical Center
Worcester, Massachusetts
Introduction
Limb salvage surgery includes all of the surgical procedures designed to accomplish removal of a malignant
tumor and reconstruction of the limb with an acceptable oncologic, functional, and cosmetic result. In the recent
past, most sarcomas were treated by amputation. 1,2 Tumor recurrence, metastasis, and a generally dismal
prognosis were a powerful deterrent to progress in treatment. Limb salvage surgery has all but replaced
amputation as the treatment of choice for sarcomas of the extremities. 1 This dramatic change came about as
the result of two important developments: effective chemotherapy 35 and precision imaging techniques. 69 In the
early 1970’s, new anti—neoplastic drugs such as adriamycin and methotrexate were introduced, and
remarkable improvements in the prognosis for some sarcomas were seen. 2’3 In the late 1970’s, the
development of CT and MRI allowed doctors to more precisely define the anatomic extent of the tumor, making
it easier to remove the sarcoma without resorting to amputation. Today, up to 85% of sarcomas in the
extremities are treated with limb salvage surgery. 3,68
Early Management and Referral
A successful limb salvage depends on a well—coordinated and timely series of events that begins with the first
physician to see the patient. The physician who suspects a malignant tumor should do a thorough history and
general examination. The basic work-up should include high quality plain radiographs for bone lesions 10 and an
MRI for soft tissue tumors.’0’11
If these basic investigations reveal a potential bone or soft tissue sarcoma, the next step would be to initiate a
referral to a specialist, preferably by phone or by personal contact. The referring physician should not undertake
an extensive work—up until this contact has been made. The choice and sequence of imaging and diagnostic
tests should be carefully coordinated between the two physicians.
Evaluation of the images by an experienced orthopedic oncologist or musculoskeletal radiologist can often
narrow the differential diagnosis through one or two entities. Sometimes the tumor may be found to be a benign
or post—traumatic process, and multiple expensive tests may never be needed. Biopsy is not a part of the initial
management of these lesions and is usually the last step in the work—up. Except in rare instances, the biopsy
should be performed by the surgeon who will be doing the definitive surgery. 11, 13 Biopsy-related
complications have been shown to lead to an amputation being required in cases where the limb might
otherwise have been salvaged.12’13 Prompt, appropriate care in the first stages of the disease has an
enormously positive impact on overall patient satisfaction and outcome.
26
Work-up
The next step in the process is the specialist’s evaluation. If the tumor is found to be aggressive or malignant, a
complete staging work-up is arranged, and the team of physicians who will collaborate in the patient’s care is
assembled. Typically, this multidisciplinary team includes orthopedic, surgical, medical and radiation
oncologists, as well as a musculoskeletal radiologist, a pathologist, and a clinical psychologist or social worker.
14-16
For bone and soft tissue sarcomas, the basic staging work—up should include high quality plain radiographs of
the affected bone or soft tissue area, a magnetic resonance imaging study of the entire tumor and nearby
anatomic structures, a computed tomography scan of the chest, a whole body technetium bone scan, and a
biopsy of the tumor.10”4 The best location and method for the biopsy is selected based on the results of the
staging work—up, and the experience and skills of the care team. The biopsy site must be carefully planned
and located along so-called “limb—salvage lines” (Figure 1), so that the entire biopsy track can be excised en
bloc with the tumor if limb salvage surgery becomes necessary.15 Biopsy is a technically simple procedure but a
complex cognitive skill that requires thoughtful consideration of every diagnostic possibility. 12
Staging
Both imaging studies and biopsy results are used to stage bone and soft tissue sarcomas according to the
system devised by William Enneking,10’14 and modified and adopted by the Musculoskeletal Tumor Society
and later, the American Joint Committee for Cancer.’0 The system combines the biopsy findings with the local
extent of the tumor to determine the stage. The biopsy material is examined for malignant features and the
histologic grade is determined. The imaging studies are examined to determine the local extent of the tumor
(Figure 2).
Staging the tumor allows the treatment team to plan and implement any appropriate preoperative chemotherapy
or radiation treatments, and allows the surgeon to begin planning the limb salvage procedure. Preoperative
chemotherapy and radiation therapy may facilitate limb salvage surgery by making a previously unresectable
tumor amenable to surgery.13
Patient Education
The preoperative treatment period provides an opportunity for the surgeon to meet with the patient and family to
discuss the choice of surgical treatment. The patient and the patient’s
family should be given the opportunity to participate in the decision—making process to the greatest extent
possible. Treatment by amputation remains a viable and sometimes preferable option and should be openly
discussed with the patient in an unbiased manner. The physician should try to help the patient understand what
effect the treatment will have on the patient’s lifestyle and mobility in practical terms. When the patient and the
family are fully informed and participate in the choice of treatment, they are much more likely to be satisfied with
the ultimate outcome, even if complications and problems arise. 17
Indications for Limb Salvage Surgery
Currently, every patient with a malignant tumor of the extremity should be considered for limb salvage if the
tumor can be removed with an adequate margin and the resulting limb is worth saving. An adequate margin is
one that results in an acceptably low rate of local recurrence of the tumor. A limb worth saving needs an
acceptable degree of function and cosmetic appearance with a minimal amount of pain, and needs to be
durable enough to withstand the demands of normal daily activities. Balancing these sometimes conflicting
requirements is what makes limb salvage surgery a complex, difficult, and rewarding process.
The patient’s prognosis has a limited impact on the decision to perform limb salvage surgery. The ability to
predict the survival of any particular patient is quite limited, and some of the most valuable information is
unavailable until after the limb salvage procedure is completed.2’3’11’18 While there are patients with advanced
26
disease who clearly will not benefit from limb salvage, there is no justification for limiting the limb salvage
process based only on the patient’s prognosis.
In selected cases, limb salvage can be combined with metastasectomy. For patients with uncontrollable
disease, limb salvage should be considered if the surgery can be accomplished
with minimum morbidity and rapid return to function. These patients can enjoy relief from pain, improved quality
of life, and intact body image that limb salvage can offer, even if they may not survive long—term.
Treatment of a sarcoma in an extremity by modern multidisciplinary techniques is an enormously costly
process, and there is no consensus as to whether limb-salvage surgery is more or less expensive than
treatment by amputation alone. In 1995 the Musculoskeletal Tumor Society found no significant difference in
cost between various techniques of limb salvage and amputation, although the participants agreed that true
cost data were not available to validate their findings.
Barriers to Limb Salvage
Barriers to limb salvage include poorly placed biopsy incisions, major vascular involvement, incasement of a
major motor nerve, pathological fracture of the involved bone, and others.19~22 These adverse factors should
not be viewed as absolute contraindications. 21,23,26
The so-called “three strikes rule” is a simple but helpful method of assessing the feasibility of limb salvage in
any particular case. Each “strike” represents involvement of one of the four key components needed for a viable
limb: the bone, the nerves, the vessels, and the soft tissue envelope. If just one or two of these key
components must be resected in order to obtain an adequate margin around the tumor, then the limb may be
salvageable. If three of these key components are involved, limb salvage is probably not worth considering.
Surgical Resections and Reconstructions
The cornerstone of a limb salvage procedure is a complete resection of the tumor with an adequate margin.
Margins can be defined as intralesional, marginal, wide, and radical (Figure 3). An intralesional margin is
created if the tumor is entered or cut into at any point during surgery. A marginal margin is created when the
surgical dissection extends into or through the abnormal, reactive tissues that surround the tumor but are not
actually a part of the tumor, the so-called “reactive zone.” A wide margin is created when the reactive zone is
not entered, but instead the dissection is through entirely normal tissues, and a cuff of normal tissue is left on all
sides of the tumor. A radical margin is created if the surgeon resects the entire bony or myofascial
compartment or compartments containing the tumor.14
Exactly what constitutes an adequate margin in any particular case remains controversial. 14 For high grade
sarcomas, a wide margin is considered adequate and will achieve successful control of the primary tumor
approximately 95% of the time, whereas marginal or intralesional margins are associated with frequent local
recurrence and poor outcomes. 7,28 In low grade tumors or in high grade tumors where preoperative radiation
therapy has been given, a marginal margin 27 may be adequate. In practice, the line between a wide and a
marginal margin is sometimes difficult to define as the surgeon strives to control the tumor while still leaving the
patient with a useful limb.
After completion of the tumor resection, the surgeon must reconstruct the resulting surgical defect. For most
soft tissue tumors, a complex reconstruction is not required. occasionally, the reconstruction or substitution of a
segment of artery or nerve may be required. The surgeon must eliminate potential deadspace and transfer
tissues if necessary to allow an effective closure. Many bone sarcomas occur in the metaphyseal portion of the
bone, so that the typical resection involves the whole proximal or distal part of the bone (Figure 4). If the joint is
not contaminated by the tumor, an intra—articular resection is performed through the joint. If the joint is
contaminated, then an extra—articular resection is required, taking the entire joint and joint capsule, and cutting
through the uninvolved bone on the other side of the joint to achieve a wide margin. For tumors that involve the
diaphyseal portion of a bone, an intercalary resection and reconstruction can be performed that saves the joints
at either end.
26
Small resected segments of bone should be reconstructed using autogenous bone from the patient’s iliac crest
or other sites, but the available supply is strictly limited. In most cases the excised segment of bone must be
replaced, either by a large internal prosthesis, a segment of allograft bone, a composite of an allograft and a
prosthesis, or by other methods.
Megaprosthesis
A megaprosthesis is a large metallic device designed to replace the excised length of bone and the adjacent
joint (Figure 5). Modular designs are available for the most common uses in the femur, tibia, and humerus that
allow the surgeon to assemble the prosthesis intra—operatively to accommodate the needs of a particular
patient. Custom prostheses are available for special applications .
The prosthetic joint must be of a modified hinge design to substitute for the stability normally provided by the
capsular and ligamentous structures that were sacrificed by the resection. The prosthesis is normally fixed to
the host bones with polymethylmethacrylate cement. Special attention is paid during closure to ensure that the
prosthesis is fully covered by a healthy soft tissue envelope. 22,24
The advantage of a megaprosthesis is that they are available “off the shelf” in a wide range of sizes and
features to suit many reconstructive needs. Fixation with cement gives the 15 reconstruction immediate stability
and allows rapid mobilization of the patient following surgery.
Regardless of the method of fixation to the host bone, the prosthesis may loosen over time. Mechanical wear of
the polyethylene bearing surfaces and the metal joints between segments of a prosthesis can lead to early or
late failure of the reconstruction. The reattachment of muscle tendons to the prosthesis is difficult and can lead
to loss of motor power or full range of motion of the joint.22’29 When these implants fail, revision procedures have
generally been successful after implantation of a new prosthesis.
Allografts
The allograft is harvested under sterile conditions, and the cartilage is protected with a cryoprotectant. 30 The
graft can be stored indefinitely at -80 degrees C. 3l and is made available after bacteriologic and viral
control.4’30’31 No suppression of the host’s immune response is necessary. After the tumor resection, an allograft
that has been carefully size-matched to the intended recipient is cut to the appropriate shape (Figure 6). The
shaft of the allograft is fixed to the end of the host bone with a bone plate or an intramedullary rod. For
osteoarticular allograft reconstructions of a joint, an allograft with intact joint capsule and ligaments that
matches the articular size and geometry of the resected specimen as closely as possible is selected. Heavy,
non—absorbable sutures are used to join the capsule and ligaments of the allograft to their counterparts on the
host bone. Muscle insertions are repaired to the stumps of tendons on the allograft.
If a sufficient inventory of allografts is available, a substitute for virtually any excised bone segment can be
obtained. The attachment of muscle insertions is more successful in allografts than in prostheses, yielding
better function in some sites. Initial enthusiasm for allografts has been tempered by a variety of problems as
experience has accumulated.32’33 While it was initially hoped that massive allografts would become fully
incorporated into the host, retrieval data show that only a small percentage of the allograft actually becomes
revascularized, while the rest remains necrotic.34’35 Rather than a biologic replacement for the excised bone
segment, the allograft functions as a biologic spacer.19’35 Massive allografts are susceptible to fractures and
infection,32 and adjuvant treatment with chemotherapy and radiation increase the complication rate. 31’32 The
articular cartilage is subject to degenerative changes.31’36 An additional concern is the potential for the
transmission of bacterial or viral disease.37’38 Although numerous problems continue to limit the success of
allograft reconstructions, they remain a viable choice for selected uses,39 especially in the upper extremity, for
intercalary resections, 40 and for patients who will not need chemotherapy.
26
Alloprosthetic Composite and Others
Some surgeons prefer to use a composite of an allograft and a prosthesis for certain limb salvage
reconstructions. (Figure 7). An appropriate allograft is selected and implanted to replace the segment of bone
resected. 33 The articular surfaces of the graft are excised and replaced using conventional techniques of total
joint arthroplasty. The allograft provides a source of bone stock and a site for tendon insertions, while the
prosthesis provides a reliable and stable articulation and some support for the allograft. The surgeon can
customize the implant for any particular need.
Other techniques are available for special circumstances. An intercalary bone defect can be filled with autograft
or spanned with a vascularized free fibula, 41 or by a new experimental technique using the concept of
distraction osteogenesis as popularized by Ilizarov and others.42
Limb Salvage Procedures in the Upper Extremity
The location of the tumor has an important impact on the choice of technique for limb salvage. A reconstruction
that combines the mobility and stability of the shoulder joint required for optimal upper extremity function is a
major technical challenge.
The functional results of limb salvage reconstructions involving the shoulder joint depend largely on the extent
of the resection. 43,45 Osteoarticular allografts of the proximal humerus allow effective reattachment of the
rotator cuff and deltoid muscles, and demonstrate better stability, function, and overall motion. Use of a
megaprosthesis for reconstruction of this type of surgical defect is popular, but has been associated with a
significant rate of shoulder instability.45
Patients whose tumor invades the shoulder joint require an extra—articular resection that includes the proximal
humerus and all or part of the scapula. If enough of the scapula is intact, a scapulohumeral arthrodesis of the
shoulder can be performed using an allograft to bridge the bony gap (Figure 8). This type of reconstruction can
lead to an excellent functional result.
The distal radius is another relatively common site for aggressive bone tumors. The ipsilateral fibula may be
used as vascularized or non—vascularized autograft to replace the distal radius and may be the best method
if available.41 Allograft reconstructions of the distal radius can yield favorable functional results. 46
Sarcomas in the hand are associated with a relatively high rate of local recurrence and a worse overall
prognosis.47 A wide resection is paramount, and amputation should be considered if a reasonable amount of
function cannot be spared. Reconstructive efforts are generally limited to maximizing the function of the
remaining hand structures.
Limb Salvage Procedures in the Lower Extremity
The proximal thigh is the most common locations for many soft tissue sarcomas, and the proximal femur is a
frequent location of bone sarcomas. The proximity of the femoral vessels, as well as the peritoneum and
retroperitoneum, make the surgical treatment of soft tissue tumors a challenge in this location. 4850 Recurrence is
a problem in large, proximal soft tissue tumors. Despite these challenges, limb salvage is a preferable
alternative to treatment by amputation, which would
require a hemipelvectomy. Most soft tissue sarcomas do not require a complex reconstruction provided the
potential dead space can be eliminated and sufficient soft tissue coverage can be achieved. Aggressive use of
local tissue transfers or vascularized free tissue grafts is warranted. 20
Bone sarcomas in the proximal femur require the resection and reconstruction of the hip joint and proximal
femur. The results of megaprostheses and alloprosthetic composites used for the proximal femur are both
favorable.33 Proximal femoral megaprostheses become prone to dislocation if the entire capsule of the hip joint
is resected. In that case, a bipolar or monopolar prosthesis is more stable than a total joint arthroplasty. The
osteoarticular allografts used to replace the proximal femur are prone to frequent fractures 51 and results are
poor.
26
The distal femur is a common site for primary bone sarcomas. The success rate of osteoarticular allografts used
to reconstruct the distal part of the femur for sarcomas ranges from 27% to
73%. 41,51,53 Initially favorable results have deteriorated with longer follow—up. Failed osteoarticular allografts
can be successfully converted to total knee arthroplasty with a favorable overall rate of limb salvage.26
Allograft—prosthetic composites have also been used to reconstruct the distal femur. The early results show
that the technique has promise, and the outcomes are at least comparable with those of other reconstructive
methods, while some of the more troublesome complications are less frequent. 54
Tumors around the knee are also a difficult reconstructive challenge for those surgeons who prefer to replace
the bone with a megaprosthesis. 8,55,56 Studies have reported complication rates as high as 55%. 55 Despite
these problems, many surgeons prefer to use a megaprosthesis for the reconstruction of the distal femur due to
their predictably good function, immediate functional restoration, the avoidance of delay in resumption of
chemotherapy in high-grade sarcomas.Reconstruction of the proximal tibia is complicated by the relatively thin
soft tissue envelope present in the area, the proximity of the neurovascular structures to the bone, and the need
to restore the insertion of the extensor mechanism to achieve satisfactory function.
When a megaprosthesis is selected, routine transfer of the medial gastrocnemius is recommended to help
provide coverage for the prosthesis and enhance the healing and function of the extensor reattachment.
Osteoarticular allografts generally provide better extensor function than prostheses, although only small series
and short follow—up have been reported, and results have been seen to deteriorate with time. 9 An
alloprosthetic composite is a favorable technique for the proximal tibia, due to the superior function of the
extensor mechanism attachment, and the fact that the stem of the prosthesis supports the allograft and helps
prevent fractures. Fixing the prosthesis to the graft with antibiotic-impregnated polymethylmethacrylate cement
may reduce the incidence of infections.
For sarcomas that occur in the lower part of the leg, ankle,and foot, the probable outcome of the salvage
procedure must be weighed against the results that might be expected after an amputation for a tumor in the
same location. For tumors in the most distal part of the leg, the function, durability, and cosmetic results after
treatment by amputation and prosthetic fitting are quite good.57 Small, low grade tumors can be successfully
treated with limb salvage. For high grade tumors, limb salvage might be technically possible and seem like a
tempting prospect, but the results are often inferior to amputation.
Functional and Psychological Outcomes
The functional outcome of the limb salvage is related to the extent of the resection, as well as the technique of the
reconstruction. Detailed functional comparisons of different techniques of limb salvage are rare. 58 Several authors have
5 9—61 compared functional outcomes of limb salvage and amputation. Patients with amputations are more
active and are the least worried about limb injury, but have the most impaired ambulation. Those with an
arthrodesis of the knee perform the most demanding physical and recreational activities, but have difficulty
sitting. Limb salvage patients have higher overall functional scores  62 Both patients with amputations and
patients who have limb salvage report a mild diminution in quality of life. Studies have failed to show a
consistently significant difference between the two groups.60’63 Amputees may be more prone to feel
unattractive, report difficulties finding a partner or developing sexual relationships, are embarrassed by their
prosthesis, and restrict their social activities to some degree. 9,59,62
Conclusion
In the past twenty years, limb salvage has become the accepted standard of care for patients with sarcomas of
the extremities. Many patients who once would have had an amputation are now having their limb saved. The
success of limb salvage depends on prompt detection and early referral by the primary care doctor, and on a
coordinated and carefully thought out sequence of staging, preoperative treatment, limb salvage surgery, and
post—salvage support and follow-up by a dedicated team of care givers.
The goals of limb salvage are the complete eradication of the tumor with minimal complications while
maintaining acceptable function, durability, and cosmesis of the limb. The limb salvage surgeon must consider
the barriers to limb salvage that may exist in each particular case. Achieving a surgical margin that will ensure a
26
low rate of local recurrence is paramount. The selection of the surgical technique for reconstruction depends on
the wishes of the patient, the location of the tumor, and the extent of the surgical defect created by the
resection. A variety of techniques are available so that the procedure most suitable for a particular situation can
be selected. In certain cases and especially in tumors in the distal lower extremity, treatment by amputation
may be preferable to limb salvage. Both limb salvage and amputation result in mild physical and psychological
disabilities. Patients adapt and adjust best if they are fully informed and able to participate in the decision
making process.
References
1. Kropej D, Schiller C, Ritschl P, Salzer-Kunt M, Rainer K. The management of IIB osteosarcoma:
Experience from 1976 to 1985. Clin Orthop 1991;270:40-4.
2. Jaffe N, Patel SR, Benjamin RS. Chemotherapy in osteosarcoma. Basis for application and
antagonism to implementation: early controversies surrounding its implementation [Review) Hemotol
Oncol 1995;9:825-840.
3. Bacci G, Picci 2, Pignatti G, et al. Neoadjuvant chemotherapy for nonmetastatic osteosarcoma of the
extremities. Clin. Orthop 1991;270:87-98.
4. Mankin HJ, Gebhardt MC, Jennings LC, Springfield DS, Tomford WW. Long—term results of allograft
replacement in the management of bone tumors. Clin Orthop 1996;324:86—97.
5. Roberts P, Chan D, Grimer RJ, Sneath RS, Scales JT. Prosthetic replacement of the distal femur for
primary bone tumors. J Bone Joint Surg [Br] 1991;73-B(5):762-9.
6. Sim FH, Beauchamp CP, Chao EY. Reconstruction of musculoskeletal defects about the knee for
tumor. Clin Orthop 1987;22l:188-201.
7. Ward WG, Yang R-S, Eckardt JJ. Endoprosthetic bone reconstruction following malignant tumor
resection in skeletally immature patients. Orthop Clin N Am
1996;27(3) :493—502.
8. Malawer MM, Chou LB. Prosthetic survival and clinical results with use of large—segment
replacements in the treatment of high—grade bone sarcomas. J Bone Joint Surg
[Am] 1995;77-A:1154-65.
9. Brien EW, Terek RM, Healey JH, Lane JM: Allograft reconstruction after proximal tibial resection for
bone tumors. Clin Orthop 1994;303:116-27.
10. Massengill AD, Seeger LL, Eckardt JJ. The role of plain radiography, computed tomography, and
magnetic resonance imaging in sarcoma evaluation. Hematol Oncol Clin N Am
1995;9(3):571-604.
11.
Kraybill WG, Emami B, Lyss AP. Management of soft tissue
sarcomas of the extremities [see comments]. Surgery
1991;109(3 Pt 1) :233—5.
12. Mankin HJ, Mankin CJ, Simon MA. The hazards of the biopsy, revisited. Members of the Musculoskeletal
Tumor Society
[see comments]. J Bone Joint Surg [Am] 1996;78-A(5)65663.
13. Springfield DS, Rosenberg A. Biopsy: complicated and risky [editorial; comment]. J Bone Joint Surg [Am]
1996;78-A(S) :639—43.
14. Wolf RE, Enneking WF. The staging and surgery of musculoskeletal neoplasms. Orthop Clin N Am 1996;
27(3) :473—81.
15. Peabody TD, Simon MA. Making the diagnosis: keys to a
successful biopsy in children with bone and soft—tissue tumors. Orthop Clin N Am 1996;27(3):4539.
16. Wilson AN, Davis A, Bell RS, et al. Local control of soft tissue sarcoma of the extremity: the
experience of a multidisciplinary sarcoma group with definitive surgery and radiography. Eur J Cancer
1994;30A:746-51.
31
17. Skrzynski MC, Biermann JS, Montag A, Simon MA. Diagnostic accuracy and charge—savings of
outpatient core needle biopsy compared with open biopsy of musculoskeletal tumors [see comments].
J Bone Joint Surg [Am] 1996;78-A(5):644-9.
18. Bacci G, Picci P, Ferrari 5, et al. Prognostic significance of serum alkaline phosphatase
measurements in patients with osteosarcoma treated with adjuvant or neoadjuvant chemotherapy.
Cancer 1993;71:1224-34.
19. Veth RP, van Hoesel QG, Bokkerink JP, Hoogenhout J, Pruszczxynski M. The art of limb salvage in
musculoskeletal oncology (Review). Critical Reviews in oncology/Hematology
1995.
20.
Steinau HU, Buttemeyer R, Vogt P, Hussmann J, Hebebrand D. Limb salvage and reconstructive
procedures in soft tissue sarcomas of the extremities. Rec Res Ca Res 1995;138:31-9.
21. Scully SP, Temple HT, O’Keefe RJ, Mankin HJ, Gebhardt M. The surgical treatment of patients with
osteosarcoma who sustain a pathologic fracture. Clin Orthop 1996;324:227-32.
22. Malawer MM. Chapter 17. Distal femoral resection for sarcomas of bone. In: Sugarbaker PH,
Malawer MM, eds. Musculoskeletal surgery for cancer. New York: Thieme Medical Publishers,
1992:243—59.
23. Koperna T, Teleky B, Vogl S., et al. Vascular reconstruction for limb salvage in sarcoma of the lower
extremity. Arch Surg 1996;13:1103-7.
24. Nichter LS, Menendez LR. Reconstructive considerations for limb salvage surgery. Orthop Clin N Am
1993;24(3):511-21.
25.
Campanacci DA, Ceruso M, Angeloni R, et al. Conservative treatment and microsurgical
reconstruction for recurrent extracompartmental high grade soft tissue sarcomas. Eight International
Symposium in Limb Salvage (ISOLS), Florence, Italy, 1995, pp 55.
26. DeGroot H. Outcomes of total knee arthroplasty in patients having an existing massive osteoarticular
allograft around the knee. Poster presentation for AAOS meeting, San Francisco, CA, 1997.
27. Ozaki T, Lindner N, Hillmann A, Rodl R, Blasius 5, Winkelmann W. Influence of surgical margins on
outcome in patients with chondrosarcoma. Eight International Symposium in Limb Salvage (ISOLS),
Florence, Italy, 1995, pp 20.
28. McGrath B, Nelson T, Scarborough M, Spanier 5, Enneking WF.osteosarcoma around the knee:
the effect of the surgical
margin at the neurovascular bundle. Eight International Symposium in Limb Salvage (ISOLS),
Florence, Italy, 1995, pp 34
29. Malawer MM. Chapter 19. Limb-sparing surgery for malignant tumors of the proximal tibia. In: Sugarbaker
PH, Malawer MM, eds. Musculoskeletal surgery for cancer. New York:
Thieme Medical Publishers, 1992:270—81.
30. Tomford WW, Mankin HJ, Friedlander GE, Doppelt SH, Gebhardt MC. Methods of bone banking and
cartilage for allograft transplantation. Orthop Clin N Am 1987;18:241-7.
31. Strong DM, Friedlaender GE, Tomford WW, Springfield DS, Shives TC, Burchardt H, Enneking WF, Mankin
HJ. Immunologic responses in human recipients of osseous and osteochondral allografts. Clin Orthop
1996;326:107-14.
32. Lord CF, Gebhardt MC, Tomford WW, Mankin HJ. Infection in bone allografts. J Bone Joint Surg [Am]
1988;70-A:369-76.
33. Zehr RJ, Enneking WF, Scarborough MT. Allograft-prOsthesis composite versus megaprosthesis in
proximal femoral reconstruction. Clin Orthop 1996;322:207—23.
34. Enneking WF, Mindell ER. Observations on massive retrieved human allografts. J Bone Joint Surg [Am]
1991;7335. Kocialkowski A, Wallace A, Harvey L. Fate of frozen intercalary allograft at one year after implantation with
adjuvant chemotherapy treatment: A case report. Clin Orthop1991;272 :146—51.
36. Malanin TI, Mnaymneh W, Lo HK, Hinkle DK. Cryopreservation of articular cartilage. Clin Orthop
1994;303:18-32.
37. Simonds RJ, Holmberg SD, Jurwitz RL, et al. Transmission of human immunodeficiency virus Type 1 from a
seronegative organ and tissue donor. N Engl J Med 1992;326:726-32.
35
38. Friedlaender GE, Goldberg VM (ed.) Bone and Cartilage Allografts, AAOS Symposium, 1991, chap 14, pg
199.
39. Ortiz-CruZ E, Gebhardt MC, Jennings LC, Springfield DS, Mankin HJ. The results of transplantation of
intercalary allografts after resection of tumors. J Bone Joint Surg [Am]1997; 79—A: 97—106.
40. Folleras G, Bjerkreim I. Allografts in the upper and lower extremity. Eight International Symposium in Limb
Salvage (ISOLS), Florence, Italy, 1995, pp 22.
41. Springfield D. Autograft reconstructions. Orthop Clin N Am
1996;27(3) :483—92.
42. Tsuchiya H. The Ilizarov method in the management of giant-cell tumours of the proximal tibia. J Bone Joint
Surg [Br]1996;78-B:264-9.
43. O’Connor MI, Sim FH, Chao EY. Limb salvage for neoplasms of the shoulder girdle. Intermediate
reconstructive and functional results. J Bone Joint Surg [Am] 1996;78-A1872-88.
44. Malawer MM. Tumors of the shoulder girdle: technique of resection and description of a surgical
classification. Ortho Clin N Am 1991;22:7-35
45. Gebhardt MC, Roth YF, Mankin HJ. osteoarticular allografts for reconstruction in the proximal part of the
humerus after excision of a musculoskeletal tumor. J Bone Joint Surg [Am)1990;72-A: 334—45.
46. Kocher MS, Gebhardt MC, Mankin HJ. Osteoarticular allograft reconstruction of the distal radius after
skeletal tumor excision. Submitted for publication, 1997.
47. Brien E, Terek R, Brennan M, Healey J. Management of soft tissue sarcomas of the hand. Eight
International Symposium in Limb Salvage (ISOLS), Florence, Italy, 1995, pp 58.
48. Ogihara Y, Fujinami 5, Sudo A. Treatment of large soft tissue sarcomas in the groin. Eight International
Symposium in Limb Salvage (ISOLS), Florence, Italy, 1995, pp 54.
49. Choong PFM, Pritchard DJ, Bertoni F, et al. Soft tissue sarcoma of the popliteal fossa: experience at the
Mayo Clinic and Rizzoli Orthpaedic Institute. Eight International Symposium in Limb Salvage (ISOLS),
Florence, Italy, 1995, pp 56.
50. Yang RS, Lane JM, Al-Shaikh R, Kelly CM, Eckardt JJ, Eilber FR, Dorey F. High grade soft tissue sarcoma
in the flexor fossae. Eight International Symposium in Limb Salvage (ISOLS), Florence, Italy, 1995, pp 57.
51. Jofe MH, Gebhardt W, Tomford WW, Mankin HJ. Reconstruction
for defects of the proximal part of the femur using allograft arthroplasty. J Bone Joint Surg [Am] 1988;70-A:
507—16.
52. Zatsepin ST, Burdygin VN. Replacement of the distal femur and proximal tibial with frozen allografts. Clin
Orthop
1994; 303:95—102.
53. Mnaymneh W, Malinin TI, Lackman RD, Hornicek FJ, GhandurMnaymneh L. Massive distal femoral
osteoarticular allografts after resection of bone tumors. Clin Orthop
1994 ;303:103-15.
54. Gitelis 5, Piasecki P. Allograft prosthetic composite arthroplasty for osteosarcoma and other aggressive
bone tumors. Clin Orthop 1991;270:197-201.
55. Capanna R, Morris HG, Campanacci D, Del Ben M, Campanacci M. Modular uncemented prosthetic
reconstruction after resection of tumors of the distal femur. J Bone Joint Surg [Br] 1994;76—B: 178—86.
56. Unwin PS, Cannon , Grimer RJ, Kemp HBS, Sneath RS, Walker PS. Aseptic loosening in cemented custom—made
prosthetic replacement for bone tumors of the lower limb. J Bone Joint Surg [Br] 1996;78—B:5—13.
57. Rodriguez RP. Amputation surgery and prostheses. Orthop Clin N Am 1996;27(3):525—39.
58. Simon MA. Limb salvage for osteosarcoma in the l980s. Clin Orthop 1991;270:264—70.
59. Harris IE, Leff AR, Gitelis 5, Simon MA. Function after amputation, arthrodesis, or arthroplasty for tumors
about the knee. J Bone Joint Surg [Am] 1990;72(l0)1477-85.
60. Rougraff BT, Simon MA, Kneisl JS, Greenberg DB, Mankin HJ. Limb salvage compared with amputation for
osteosarcoma of the distal end of the femur. A long-term oncological, functional, and quality-of-life study. J
Bone Joint Surg
[Am] 1994;76—A(5) :649—56.
61. Otis JC, Lane JM, Kroll MA. Energy cost during gait in osteosarcoma patients after resection and knee
replacement and after above—the—knee amputation. J Bone Joint Surg[Am] 1985;67-A:606-11.
44
62.
Postma A, Kingma A, De Ruiter JH, Schraffordt Koops H, Veth RP, Goeken LN, Kamps WA. Quality of
life in bone tumor patients comparing limb salvage and amputation of the lower extremity. J Surg oncology
1992;51:4751.
63. Sugarbaker PH, Barof sky I, Rosenberg SA, Gianola FJ. Quality of life assessment of patients in extremity
sarcoma clinical trials. Surgery 1982;91:17—23.
Figure Legends
Figure 1. “Limb Salvage Lines” for Biopsy Placement.
If possible, the biopsy site should be located along limb salvage lines. The entire biopsy track can then be excised with the
tumor at the time of definitive surgery.
Figure 2. staging System for Extremity Sarcomas. A diagram of the tumor staging system of the Musculoskeletal Tumor
Society. Histologic grade is determined from biopsy material. Local extent of the tumor is determined by imaging studies.
Grade and local extent are combined to determine the stage of a tumor.
Figure 3. surgical Margins in Limb Salvage Surgery. Surgical margins are defined as intralesional, marginal, wide, and
radical. Intralesional margins are created when the surgical dissection enters the tumor. Marginal margins are created when
the surgical dissection enters the abnormal tissue in the reactive zone around the tumor. Wide margins are created when the
dissection is entirely outside the reactive zone and a cuff of normal tissue is left on all portions of the tumor. Radical
margins are created by resection of all of the bony or myofascial compartments that contain the tumor.
Figure 4. Limb Salvage Surgery Resection Levels for Different Tumor Locations.
The surgeon must adjust the resection level to achieve a wide margin. When the joint is not contaminated by the tumor,
intra—articular resections can be performed. When the joint is contaminated by tumor, extra—articular resection is
required. When the tumors are limited to the diaphyseal or metadiaphyseal portion of a bone, intercalary resections can
yield a wide margin while both adjacent joints are spared.
Figure 5. Surgical View of a Limb Salvage Reconstruction with a Megaprosthesis.
A megaprosthesis is a metallic implant designed to replace the excised bone segment along with the adjacent joints.
Modular designs allow for the intraoperative customization of the protheses to suit many types of tumor resection.
Figure 6. Surgical View of a Limb Salvage Reconstruction with an osteoarticular Allograft
A size—matched osteoarticular allograft is fixed to host bone with a plate. The capsule and ligaments of the allograft are
sutured to their counterparts in the host, and major muscle tendons can be sutured to their anatomic sites of insertion on the
allograft. The allograft retains structurally normal articular cartilage on its joint surface.
Figure 7. Diagrammatic View of an Alloprosthetic Composite An appropriate size-matched allograft is selected to replace
the resected bone segment. The articular surface of the allograft is replaced with a cemented total joint prothesis. The
allograft provides bone stock and tendon insertion sites; the prosthesis provides stable, reliable joint function.
Figure 8. Diagrammatic View of a Shoulder Alloarthrodesis. The left hand figure shows the resection levels required when
a tumor of the proximal humerus has contaminated the joint. The right hand figure shows an alloarthrodesis. An
appropriate allograft is used to replace the resected bone. The articular surfaces are removed and the joint is immobilized
with a plate while fusion occurs.
44
Henry Degroot, M.D.
Limb Salvage SurgeryFigure 2
44
44
Intraarticul
Henry Degroot, M.D.
Limb Salvage Surgery Inter
Figure 4 calar
y
-
ar
t
Resections
Extra
articular
Henry Degroot, M.D.
Limb Salvage Surgery
Figure 4 Resections
-
Extra
articular
lntra
articul
ar
Inter
calar
y
44
44
44
C’)

F
21~I
CO CD CD
CO fl
‘V
CO
0%-,
CO CD 0
.2.
ci
44
6
C) C)
0 ~
Qc~
Cl)
44
Henry Degroot
Limb Salvage
Fig. 8 Alloarthrodesis
-
44
Henry Degroot, M.D.
Limb Salvage Lines
Figure 7 Allograft
-
Henry Degroot, M.D.
Limb Salvage Lines
Figure 7 Allograft
-