Limb-sparing procedures

In general, more than 80% of patients with extremity osteosarcoma can be treated using a limb-sparing procedure and do not require amputation.[8] Limb-sparing procedures are planned only when the preoperative staging indicates that it would be possible to achieve wide surgical margins. In one study, patients who underwent limb-salvage procedures who had poor histological response and close surgical margins had a high rate of local recurrence.[9]

Reconstruction after limb-sparing surgery can be accomplished with many options, including metallic endoprosthesis, allograft, vascularized autologous bone graft, and rotationplasty. An additional option, osteogenesis distraction bone transport, is available for patients whose tumors do not involve the epiphysis of long bones.[10] This procedure results in a stable reconstruction that functionally restores the normal limb.

The choice of optimal surgical reconstruction involves many factors, including the following:[11][Level of evidence A1]

If a complicated reconstruction delays or prohibits the resumption of systemic chemotherapy, limb preservation may endanger the chance for cure. In retrospective analyses of 703 patients with localized osteosarcoma, the resumption of chemotherapy 21 days or more after definitive surgery was associated with an increased risk of death and adverse events (hazard ratio [HR], 1.57; 1.04–2.36).[11] Delays in total time to completion of chemotherapy have also been associated with inferior OS and event-free survival (EFS). In a retrospective multivariate analysis of 113 patients with localized osteosarcoma, a delay of time to completion of chemotherapy greater than 4 weeks was associated with an OS HR of 2.70 (1.11–6.76, P = .003) and an EFS HR of 1.13 (1.00–1.26, P = .016).[12]