Extremity bone sarcomas are rare and pose a challenging problem for patients and their physicians. Physicians who treat bone cancer are called orthopaedic oncologists.
Osteosarcoma is the most common primary bone malignancy that is considered for limb salvage, although there are other types of bone cancer. The National Cancer Institute provides comprehensive information on bone cancer. Approximately 400 osteosarcomas are diagnosed in the United States each year. The majority of these bone cancers occur in the adolescent age group.1 A smaller number are present in children under the age of 10, and some develop in older people secondary to a pre-existing condition such as Paget's disease.
In the past, extremity bone cancers were treated by amputation with relatively poor functional outcomes. Over the last 30 years, limb salvage (operations to save the limb rather than amputate) has evolved. This technique has been proven safe and effective in most cases.
Finally, there have been major developments in limb reconstruction. Surgeons now have available implants that can be matched to the patient's size, stronger metals, bone and soft tissue allografts (transplants), microvascular and muscle transfer procedures, and bone graft substitutes. These techniques allow the limb to be restored with good function.
There are even devices that can be expanded or "grown" for children to account for normal skeletal growth lost with limb preservation.
Despite all of these improvements and the enthusiasm for limb salvage, it is not for everyone. There are contraindications and complications that need to be considered. The decision needs to be made by the patient after a detailed and lengthy discussion with their cancer surgeon. The patient needs to have a thorough understanding of the advantages and disadvantages of limb salvage before pursuing this technique.
The tumor can invade and cross the growth plate. Osteosarcoma is an invasive cancer that usually extends out of the bone into the soft tissues. The tumor can involve the joint, muscles, nerves, and arteries near the bone of origin. As the tumor progresses, it destroys bone and may lead to fracture.
Hematogenous (through the blood) spreading of this cancer is a significant risk. Patients need to be staged for distant disease. The greatest risk is spread to the lungs. The cause of this malignancy is not known. There is no hereditary link for a standard osteosarcoma. Known environmental risk factors include radiation.
The presence of micro-metastatic disease at presentation is common and is one reason for chemotherapy. End-stage patients will develop extensive pulmonary disease, and osteosarcoma will metastasize to other skeletal and nonskeletal sites.
Nonoperative treatment for osteosarcoma is not reasonable, except for tumors located in anatomically inaccessible sites. An example is a large tumor of the spine. In this case, palliative (non-curative) radiation and chemotherapy can be given.
Even patients with demonstrated pulmonary metastatic disease are treated aggressively with chemotherapy and surgery. Some of these advanced-stage patients can be cured.
The optimal treatment of osteosarcoma requires some form of surgery. Radiation can be used for inoperable tumors, but is only palliative and generally not curative.
Current treatment for osteosarcoma uses neoadjuvant (preoperative) chemotherapy for approximately three months.3, 4 The chemotherapy is given either through a vein (intravenous) or an artery (intra-arterial). Then, the patient is restaged both locally and systemically to see if the tumor has metastasized or changed in size. A decision regarding the type of surgery (limb salvage or amputation) is made.
Chemotherapy alone is not enough to control the tumor in bone.6 Surgery is needed to remove the residual viable tumor cells. After surgery, patients are placed back on chemotherapy for up to one year. If pulmonary disease develops, the nodules can be removed surgically.
The first surgical decision concerns the feasibility of limb salvage. Most osteosarcomas (approximately 85 percent) are candidates for limb preservation.
There are some relative contraindications.
Patients with tumors that infiltrate the skin around the bone are poor candidates to save the limb
Cancers that surround important nerves and arteries may need to be amputated.7
Sarcomas in very young children are best managed by amputation. In these young patients, the limb length inequality after limb preservation will be excessive and de-functionalizing.
Any patient who must decide between amputation and limb salvage must understand everything involved with both options. A consultation with a prosthetist is invaluable in understanding life with amputation. They can usually show the patient and their family an example of the prosthesis they would have, and videos showing the activities that the patient could perform. Also, most cancer surgeons can arrange meetings for a patient deciding about surgery with another patient who has already had that type of surgery.
There are considerations in deciding between limb salvage and amputations.
- Emotional. Amputations can be both emotionally and physically devastating to patients.
- Technical. Unlike limb salvage, amputations tend to be technically less complicated operations for the surgeon, resulting in few complications.
- Ongoing surgery. Patients with amputations usually need no further surgery, while limb salvage patients may need multiple surgeries throughout their lives to fix problems that occur with the initial reconstruction.
- Return to Function. Amputation patients often have a faster return to function and may even have better function than limb salvage patients.
- Prosthetics. Artificial limbs have been improved in appearance and function. These limbs have endoskeletons (shells) that can be covered with a more natural appearing material to make them look more like a normal limb.
The joint mechanisms are also very sophisticated and can return the patient to a more normal gait. A patient with a below-the-knee amputation usually walks without a limp and can play most sports. Most observers would not even know the patient, in long pants, had an amputation.
Patients with above-the-knee amputations can also function very well.8 Although they often have a minimal limp and can play many sports, they tend not to function as well as below-the-knee patients because of the need for an artificial knee joint as part of the prosthesis.
Limb-girdle amputations such as a hind-quarter (through the hip joint) can be fitted, but function is limited. Amputations closer to the hip require more energy from the patient to walk than distal amputations.
Amputation patients in general require more energy to walk compared to limb salvage patients.8
A unique amputation procedure, called the Van Ness procedure, is useful in very young children. The tibia, foot, and ankle can be preserved and fixed to the remaining femur after rotating it so the foot points backwards. The ankle joint then acts as the knee joint.9, 10, 11 These patients can be fitted as a below-knee amputee with better function than a standard above knee amputation.12 While this reconstruction always upsets the patient and their family when they initially hear about it, it is an excellent option, allowing these children to participate in almost all normal childhood activities.
Amputations of the shoulder, arm, or forearm have a poorer functional outcome than amputations of the thigh or lower leg. This is especially true for the shoulder girdle. The terminal device (artificial hand) of the prosthesis has only a limited ability to return manual strength and dexterity. Myo-electric prostheses may improve some of these deficiencies.
After a decision is made for limb salvage, there are two basic types of reconstruction in adults. Most osteosarcomas involve the knee joint, which needs to be removed during the resection.
The disadvantages include:
- Loss of functions requiring the knee to bend, such as climbing or stooping.
- Arising from a chair is difficult, as is sitting anywhere that you need a bent knee, such as a movie theater or an airplane.
- Knee arthrodesis also places abnormal stresses on the joints above and below the knee, and can lead to future hip or back problems.
- Arthrodesis also increases the energy needed for the patient to walk.
Limb salvage for tumors about the knee has two major steps: removal of the cancer and reconstruction.36
Removal of the cancer
The first part of the procedure is the complete removal of the cancer with an adequate margin. The surgeon must be certain that the knee joint is not contaminated with tumor cells. If there is joint penetration, the joint is removed as one unit. The most reasonable reconstruction following this is a knee fusion. Most of the time, the joint can be opened and the distal femur or proximal tibia resected. Muscle covering the soft-tissue component of the tumor will be taken out to improve the margin. The nerves and arteries behind the bone are often identified and protected.
Before the procedure, the bone cut is determined based on the MRI. Once the cancer has been adequately removed, the specimen is opened to be certain the margins are adequate.
The next part of the procedure is reconstruction. If a modular oncology prosthesis is the desired reconstruction (most common), the femur bone is prepared by reaming the canal of the bone with a power instrument. The desired femoral stem diameter is selected.
The tibia is next prepared by removal of its cartilage surface and preparing the canal. The trial modular device is assembled and placed in the bone to check length, stability, and patellar tracking. The patella can be resurfaced as desired. The final modular oncology device can be inserted cemented or cementless.37 Cementless devices are porous-coated and bone ingrowth is necessary for success.38 This can be a problem in the presence of chemotherapy. The wound is closed in multiple layers. The ligaments do not need to be repaired because the rotating hinge bearing provides for joint stability. For tibial tumors, muscle flaps are necessary for closure and to repair the patellar ligament.39, 40, 41
Allograft arthroplasty requires fixing the bone to the femur with a plate or rod.17, 21, 43 Rigid internal fixation is needed to promote healing. The allograft needs to be properly sized to match the bone and joint removed. All of the ligaments need to be sutured to the allograft to stabilize the joint. Instability is a significant problem with allograft arthroplasty.4, 44
In general there are more potential complications with limb salvage than with amputation.7
- Recurrence. There is less risk of local recurrence with amputation. Survival for osteosarcoma, however, is the about the same whether the patient chooses limb salvage or amputation.
- Phantom pain after amputation
- Neuroma after amputation
- Wound necrosis
- Bone prominence
- Bone overgrowth in children. This results from the bone growth potential still present in children, and may require re-amputation to shorten the growing bone.
While troubling, phantom pain and neuroma usually can be managed with medication, and in some cases, a small surgical procedure.
The complications with modular oncology prosthetic arthroplasty are numerous but usually manageable.45
- Infection. Infection is a serious problem that usually requires removal of the device before the infection can be cured.
- Wound necrosis. Wound necrosis can occur because of the extensive soft tissue dissection needed to remove the cancer. This problem can be minimized by the use of muscle flaps.
- Nerve palsy. Most of these operations require delicately separating the nerves from the tumor, which may lead to nerve palsy. The complication will usually resolve with time.
- Mechanical complications related to the prosthesis. The device can loosen or break, or the bearing (hinge) can fail. Wear of the bearing surfaces can lead to tissue reactions. Most mechanical complications can be minimized if the metallic device is used wisely. These implants are not made for functions such as running or impact athletics. Walking, biking, low impact dancing, and swimming are reasonable activities. Patients who are long-term cancer survivors will likely experience implant failure at some point in their futures.
After a lower limb amputation, the surgeon can place either a temporary prosthesis or a soft dressing. The temporary prosthesis allows earlier functional rehabilitation and is suited for an amputation at an above-the-knee level or distal. A prosthetist may be asked to place the cast pylon device on the limb in the operating room.
Physical therapy is started early for functional and psychological reasons. Therapy consists of gait training, joint mobilization, and muscle strengthening.
If a soft dressing is applied, patients are also taught how to wrap the limb to diminish swelling.
Prosthetic fabrication is usually held for about three months to allow the limb to regain its normal shape. After the leg is ready, the patient is taught how to use it. The higher the level of amputation, the more training is necessary. Patients with high level amputations may benefit from an inpatient stay at a rehabilitation center. Upper limb amputations need extensive rehabilitation by occupational and physical therapy. Prosthetic use is taught and the patient is instructed on how to use the opposite limb for activities of daily living.
Limb salvage with a modular oncology device also requires significant rehabilitation. Shortly after surgery, the patient will go to physical therapy for gait training, knee range of motion, and muscle strengthening.
If the device is placed without cement, partial weight-bearing ambulation is necessary for six weeks.
The soft tissue repair after limb salvage has a significant effect on rehabilitation. If a quadriceps reconstruction is performed, especially for proximal tibial tumors, this repair needs to heal before active exercise is started. This is usually at six weeks. Range of motion exercises are influenced by the patellar tracking and tightness of the knee.
Limb salvage with an allograft requires somewhat different rehabilitation. The allograft needs to be protected with a walking aid until healing occurs at the junction of the allograft and host bone.8
Children especially need to be encouraged during the rehabilitation process. While they continue on chemotherapy, they have a diminished energy level and lack motivation to exercise. There is a strong tendency for children to develop a knee flexion contracture, and this needs to be avoided.
In general, patients with cemented modular oncology devices recover quicker than all other forms of limb salvage and amputation.8
This is a non-exhaustive list of potential additional resources. AAOS does not review or endorse accuracy or effectiveness of materials, treatments or physicians.
|1.||Enneking WF. General Principles of Musculoskeletal Tumor Surgery Natural History. In: Enneking WF, ed. Musculoskeletal Tumor Surgery, vol. 1. New York: Churchill Livingstone, 1983:3.|
|2.||Berquist TH. Magnetic Resonance Imaging of Musculoskeletal Neoplasm. Clin Orthop 1989;244:101.|
|3.||Meyers PA, Heller G, Healey J, et al. Chemotherapy for Nonmetastatic Osteogenic Sarcoma: The Memorial Sloan-Kettering Experience. J Clin Oncol 1992;10:5.|
|4.||Brien EW, Terek RM, Healey JH, Land JM. Allograft Reconstruction after Proximal Tibial Resection for Bone Tumors: An Analysis of Function and Outcome Comparing Allograft to Prosthetic Reconstruction. Clin Orthop 1994;303:116.|
|5.||Picci P, Bacci G, Campanacci M, et al. Histologic Evaluation of Necrosis in Osteosarcoma Induced by Chemotherapy: Regional Mapping of Viable and Nonviable Tumor. Cancer 1985;56:1515.|
|6.||Link MP, Goorin AM, Miser AW, et al. The Effect of Adjuvant Chemotherapy on Relapse-Free Survival in Patients with Osteosarcoma of the Extremity. N Engl J Med 1986;314:1600.|
|7.||Simon MA, Aschliman MA, Thomas N, Mankin HJ. Limb-Salvage Treatment versus Amputation for Osteosarcoma of the Distal End of the Femur. J Bone Joint Surg Am 1986;68:1331.|
|8.||Harris IE, Leff AR, Gitelis S, Simon MA. A Comparison of Function and Walking Efficiency in Patients With Aggressive Tumors at the Knee Treated by Above-the-Knee Amputation, Knee Arthrodesis, or Knee Arthroplasty. J Bone Joint Surg Am 1990;72:1477.|
|9.||Cammisa FP, Glasser DB, Otis JC, et al. The Van Nes Tibial Rotationplasty: A Functionally Viable Reconstructive Procedure in Children Who Have a Tumor of the Distal End of the Femur. J Bone Joint Surg Am 1990;72:1541.|
|10.||Kotz R, Salzer M. Rotationplasty for Childhood Osteosarcoma of the Distal Femur. J Bone Joint Surg Am 1982;64:959.|
|11.||Merkel KD, Gebhardt M, Springfield DS. Rotationplasty as a Reconstructive Operation after Tumor Resection. Clin Orthop 1991;270:231.|
|12.||Winkelmann WW. Rotationplasty. Orthop Clin North Am 1996;27:503.|
|13.||Enneking WF, Shirley PD. Resection Arthrodesis for Malignant and Potentially Malignant Lesions about the Knee Using Intramedullary Rod and Local Bone Grafts. J Bone Joint Surg Am 1997;59:223.|
|14.||Eckardt JJ, Eilber FR, Rosen G, et al. Endoprosthetic Replacement for Stage IIB Osteosarcoma. Clin Orthop 1991;270:202.|
|15.||Weiner SD, Scarborough M, Vander Griend RA. Resection Arthrodesis of the Knee with an Intercalary Allograft. J Bone Joint Surg Am 1996;78:185.|
|16.||Gebhardt MC, Flugstad DI, Springfield DS, Mankin HJ. The Use of Bone Allografts for Limb Salvage in High-Grade Extremity Osteosarcoma. Clin Orthop 1991;270:181.|
|17.||Sim FH, Frassica FJ. Use of Allografts following Resection of Tumors of the Musculoskeletal System. Instr Course Lect 1993;42:405.|
|18.||Weinberg H, Kenan S, Lewis MM, et al. The Role of Microvascular Surgery in Limb-Sparing Procedures for Malignant Tumors of the Knee. Plast Reconstr Surg 1993;92:692.|
|19.||Clohisy DR, Mankin HJ. Osteoarticular Allografts for Reconstruction after Resection of a Musculoskeletal Tumor in the Proximal End of the Tibia. J Bone Joint Surg Am 1994;76:549.|
|20.||Mankin HJ, Doppelt SH, Sullivan TR, Tomford WW. Osteoarticular and Intercalary Allograft Transplantation in the Management of Malignant Tumors of Bone. Cancer 1982;50:613.|
|21.||Zatespin ST, Burdygin VN. Replacement of the Distal Femur and Proximal Tibia with Frozen Allograft. Clin Orthop 1994;303:95.|
|22.||Bradish CF, Kemp HBS, Scales FT, et al. Distal Femoral Replacement by Custom Made Prostheses. J Bone Joint Surg Br 1987;69:276.|
|23.||Choong PF, Sim FH, Pritchard DJ, et al. Megaprostheses after Resection of Distal Femoral Tumors. A Rotating Hinge Design in 30 Patients Followed for 2-7 Years. Acta Orthop Scand 1996;67:345.|
|24.||Kawai A, Muschler GF, Lane JM, et al. Prosthetic Knee Replacement after Resection of a Malignant Tumor of the Distal Part of the Femur. J Bone Joint Surg Am 1998;80:636.|
|25.||Morris HG, Capanna R, Campanacci D, et al. Modular Endoprosthetic Replacement after Total Resection of the Femur for Malignant Tumor. Int Orthop 1994;18:90.|
|26.||Sim FH, Frassica FJ, Chao EY. Orthopaedic Management Using New Devices and Prostheses [Review]. Clin Orthop 1995;312:160.|
|27.||Veth RPH, et al. Megaprosthesis in the Treatment of Primary Malignant Metastatic Tumors in the Hip Region. J Surg Oncol 1989;40:214.|
|28.||Gitelis S, Piasecki P. Allograft Prosthetic Composite Arthroplasty for Osteosarcoma and Other Aggressive Bone Tumors. Clin Orthop 1991;270:197.|
|29.||Kneisl JS, Finn HA, Simon MA. Mobile Knee Reconstructions after Resection of Malignant Tumors of the Distal Femur. Orthop Clin North Am 1991;22:105.|
|30.||Kenan S, Bloom N, Lewis MM. Limb-Sparing Surgery in Skeletally Immature Patients with Osteosarcoma: The Use of an Expandable Prosthesis. Clin Orthop 1991;270:223.|
|31.||Kenan S, Lewis MM. Limb Salvage in Pediatric Surgery: The Use of The Expandable Prosthesis. Orthop Clin North Am 1991;22:121.|
|32.||Lewis MM. The Use of the Expandable and Adjustable Prosthesis in the Treatment of Childhood Malignant Bone Tumors of the Extremities. Cancer 1986;57:499.|
|33.||Uwin PS, Walker PS. Extendable Endoprosthesis for the Skeletally Immature. Clin Orthop 1995;322:179.|
|34.||Kenan S, Lewis MM. Limb Sparing Surgery in Children. The Expandable Prosthesis. Current Trends and Controversies after the First 10 Years. Eighth International Symposium on Limb Salvage (ISOLS), Florence, Italy, 1995;124.|
|35.||Ward WG, Yang RS, Eckardt JJ. Endoprosthetic Bone Reconstruction following Malignant Tumor Resection in Skeletally Immature Patients. Orthop Clin North Am 1996;27:493.|
|36.||Gitelis S, Malawer A, MacDonald D, Derman G. Principles of Limb Salvage Surgery. In: Szabo RM, Marder R, Vince KG, eds. Chapman's Orthopaedic Surgery, vol.3, 3rd ed. Lippincott, Williams & Wilkins, 2001:3309.|
|37.||Capanna R, Morris HG, Campanacci D, et al. Modular Uncemented Prosthetic Reconstruction after Resection of Tumours of the Distal Femur. J Bone Joint Surg Br 1994;76:178.|
|38.||Ward WG, Johnston KS, Dorey FJ, Eckhardt JJ. Extra-medullary Porous Coating to Prevent Diaphyseal Osteolysis and Radiolucent Lines around Proximal Tibial Replacements: A Preliminary Report. J Bone Joint Surg Am 1993;75:976.|
|39.||Feldman JJ, Cohen BE, May JW Jr. The Medial Gastrocnemius Myocutaneous Flap. Plast Reconstr Surg 1978;61:531.|
|40.||Guzman-Stein G, Fix RJ, Vasconez LO. Muscle Flap Coverage for the Lower Extremity. Clin Plast Surg 1991;18:545.|
|41.||Malawer MM, Price WM. Gastrocnemius Transposition Flap in Conjunction with Limb-Sparing Surgery for Primary Bone Sarcomas around the Knee. Plast Reconstr Surg 1984;73:741.|
|42.||Senyuva C, Yucel A, Aydin Y, et al. Coverage of Knee-Tumor-Resection Prostheses with Free Flaps. J Reconstr Micro 1997;13:277.|
|43.||Jofe MH, Gebhardt MC, Tomford WW, Mankin HJ. Reconstruction for Defects of the Proximal Part of the Femur Using Allograft Arthroplasty. J Bone Joint Surg Am 1988;70:507.|
|44.||Mankin HJ, Gebhardt MC, Jennings LC, et al. Long-Term Results of Allograft Replacement in the Management of Bone Tumors. Clin Orthop 1996;324:86.|
|45.||Quill G, Gitelis S, Morton T, Piasecki P. Complications Associated with Limb Salvage for Extremity Sarcomas and Their Management. Clin Orthop 1990;280:242.|
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