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Limb-salvage surgery plays a major role in the management of patients with osteosarcoma. As prognosis improves, reconstructive options have come under greater scrutiny with regard to their durability and functionality. The advent of computer navigation-guided reconstruction is discussed in detail, along with methods by which resections can be performed more conservatively, thus facilitating less radical reconstruction. The known modalities of reconstruction, namely biological, nonbiological and composite, are described with reference to the most recent literature. We also discuss changes that have been introduced in order to reduce known complication risks, such as infection, in patients with osteosarcoma. Areas requiring further consideration are highlighted.

Background: Children rarely require hip replacement, and therefore very little is known about the most effective procedure for children who require hip replacement after proximal femoral resection for a tumor., Methods: We reviewed the outcome of forty hip replacements in children between two and fifteen years old who had a proximal femoral replacement for malignant disease. Twenty-one children survived the illness and were followed for three to twenty-one years. Cemented acetabular components were used initially to restore hip function, but, in more recent procedures, unipolar replacements and uncemented implants were used., Results: Children who were over the age of eleven years at the time of surgery had a rate of failure (defined as revision of the acetabular component) of 25% at ten years compared with a rate of 75% in younger children. Unipolar replacements in children of all ages failed by ten years, either because of pain or subluxation that led to revision. In children over the age of eleven years, both cemented and uncemented acetabular implants performed well., Conclusions: The preferred method for restoration of hip function in children under the age of eleven years following proximal femoral resection for a tumor remains unclear. We recommend that at the initial hip surgery an attempt should be made to cause as little damage as possible to the acetabulum, but most children will inevitably need revision surgery as they get older. We hope that this study will guide others in their decision-making with regard to this relatively rare condition.

The prognostic value of alkaline phosphatase (AP) measured before and after chemotherapy, but before surgery was established in a retrospective survey of patients. The patients were 18 years or older, with non-metastatic high-grade osteosarcoma. Pre-chemotherapy AP was available in 89 cases, post-chemotherapy AP in 86 patients, and both in 71 cases. AP was classified as Normal (< 100% upper limit), High (100% < or = AP < 200%) or Very High (AP > or = 200%). Osteosarcoma subtype was predominantly conventional. No correlation was found between subtype and chemotherapy response, local recurrence or survival. Pre-chemotherapy AP was raised more in the osteoblastic subtype. Post-chemotherapy AP and normalisation were the same among different subtypes. AP was not correlated with local recurrence. Normal or High pre-chemotherapy AP correlated with better survival at 10 years (64% and 70%) than Very High pre-chemotherapy AP (37%, P = 0.005). Post-chemotherapy AP correlated with survival (68%, 39% and 25% in the Normal, High and Very High group, P = 0.0007) and response to chemotherapy (P = 0.049). A pre-chemotherapy AP above twice Normal correlated with worse survival. If AP decreased after chemotherapy, but was still raised, survival was better, but still worse than if AP normalised. A raised post-chemotherapy AP predicts poor chemotherapy response.

We report on the management and outcome of 96 patients who developed local recurrence (LR) after having definitive primary treatment with chemotherapy and surgery for non-metastatic osteosarcoma. LR developed at a median of 11 months from initial surgical treatment. 18% of patients had metastases prior to the diagnosis of LR and 23% were found to have metastases synchronously. The prognosis for this group with metastases was 14% survival at 2 years. In the 57 patients without metastases at the time of development of LR, survival was 51% at 2 years and 41% at 5 years. Treatment was by excision of the LR and radiotherapy or by amputation. The only significant prognostic factors identified were the presence of metastases at the time of development of LR (P < 0.0001) and small size of the LR. The role of adjuvant chemotherapy was unclear. Whilst every attempt should be made to avoid LR, patients who develop LR are curable, particularly if they do not have metastases at the time of diagnosis of the LR.

Thirty-four patients with infected massive endoprostheses had two-stage revision procedures to cure the infection and retain a useful functioning limb. An antibiotic impregnated cement spacer constructed with two cement gun liners and a Kuntscher nail provided temporary stability and also allowed a high dose of local antibiotic concentration. In three patients the infection never was controlled, and one of these patients had a successful second revision surgery. Six other patients had reinfection varying from 14 to 92 months after surgery. Risk factors for reinfection were previous radiotherapy and any additional operative intervention. The overall success rate for controlling infection was 91% at 1 year and 74% at 5 years. Six patients required amputation. The mean functional outcome for the retained limbs using the Musculoskeletal Tumor Society scoring system was 77%. Two-stage revisions seem almost as effective at controlling infection in massive endoprostheses as in conventional joint replacements, particularly if additional surgical interventions can be avoided.

Purpose: Periosteal osteosarcomas are rare cartilage-rich bone tumours characterized by a juxtacortical eccentric position and are normally regarded oncologically as of intermediate to high grade. Their low incidence is mirrored by a small number of reported cases in the world literature. While there is general agreement that wide surgical excision is required, there is a paucity of evidence regarding adjuvant therapy. Previous reports have not indicated any consistent approach to this to allow appraisal. Patients and methods: We report 17 cases treated at our centre over 16 years. Our policy was to use chemotherapy when the tumour showed any features of high grade. Results: To date, no deaths have resulted from recurrence or metastasis of the tumour although there have been two deaths from other causes. Discussion: Comparison of survival with existing studies is made to draw conclusions regarding future treatment of this condition in terms of surgical and adjuvant approaches. [ABSTRACT FROM AUTHOR]

Purpose. Clear cell chondrosarcoma is a rare variant of chondrosarcoma. Six cases are herein reported. Subjects. We have treated six patients with clear cell chondrosarcoma in the past 28 years, representing 1.6% of all chondrosarcomas seen in this time period. Results and Discussion. Half the patients had been initially underdiagnosed and inappropriately treated. Conclusions. Our results and our review of the literature highlight the fact that inadequate initial treatment leads to a high rate of both local recurrence and metastasis whilst wide initial excision is usually curative. [ABSTRACT FROM AUTHOR]

Purpose. The purpose of this study was to analyse the height at diagnosis and growth in 72 skeletally immature children who had been treated for osteosarcoma in the area of the knee. Subjects. Of the patients, the average age at diagnosis was 10 years in girls and 12 years in boys. All children received neo-adjuvant chemotherapy, and had limb salvage by endoprosthetic replacement. Results and conclusion. The results of this study indicate that there is no evidence that children with osteosarcoma are taller at diagnosis than their normal counterparts. However, there was a marked retardation in growth in the year following the administration of cytotoxic chemotherapy. There were 19 children who reached skeletal maturity. The final height in these children was not significantly different from the normal population. [ABSTRACT FROM AUTHOR]